Method of detection and treatment of clinically significant post-prandial hyperglycemia in normoglycemic patients

ABSTRACT

This invention relates to a method for detecting the presence of or likelihood of a patient of developing occult pancreatic beta cell dysfunction, and a method for detecting the presence of or likelihood of a patient of developing clinically significant post-prandial hyperglycemia. The methods involve (a) measuring a level of alpha-hydroxybutyrate (AHB) in a single fasting baseline biological sample of the patient; (b) comparing the level of AHB in the single fasting baseline biological sample to a reference AHB level; and (c) determining the presence of or likelihood of developing the disorder in the patient based on the comparison in step (b). An increased AHB level at fasting baseline indicates that a normoglycemic, normo-insulinemic and/or non-dyslipidemic patient has developed or has an increased likelihood of developing occult pancreatic beta cell dysfunction. An increased AHB level at fasting baseline and an elevated glucose level of at least about 155 mg/dL at 30 minutes and/or 1 hour indicates that a normoglycemic, normo-insulinemic and/or non-dyslipidemic patient has developed or has an increased likelihood of developing clinically significant post-prandial hyperglycemia.

PRIORITY CLAIM

This application claims priority under 35 U.S.C. § 119(e) to U.S.Provisional Application No. 61/751,328, filed Jan. 11, 2013, U.S.Provisional Application No. 61/831,337, filed Jun. 5, 2013, and U.S.Provisional Application No. 61/831,405, filed Jun. 5, 2013, all of whichare hereby incorporated by reference in their entirety.

BACKGROUND

Currently a number of tests exist that can diagnose patients as diabeticor pre-diabetic, including pre-diabetic conditions, such as occultpancreatic beta cell dysfunction or post-prandial hyperglycemia. Suchtests include glucose, insulin, pro-insulin, c-peptide, HbA1c,fructosamine, glycation gap, 1,5-anhydroglucitol (1,5-AG), OGTT, CLIXscoring, HOMA IR scoring, and IRI scores based on combinations of AHB,L-GPC, and Oleic Acid weighted by insulin or BMI. Used alone or incombination some of these tests can detect the presence of Type 2diabetes, pre-diabetes (metabolic syndrome) and early insulinresistance. Additionally there are tests that may detect some cases ofType 1 Diabetes (T1DM, sometimes referred to as childhood-onset orearly-onset) such as anti-GAD antibody and other auto-antibodies topancreatic islet cells, as Type 1 diabetes usually involves developmentof auto-antibodies.

The best current predictors of fasting normoglycemic patients who areactually at risk of developing diabetes are OGTTs and CLIX scoring ofOGTTs. Both of these techniques involve testing multiple analytes atmultiple time-points, requiring the patient to have a blood sample drawnat baseline (fasting), drink a beverage containing a known quantity ofglucose, and subsequently contacting patient blood samples and measuringthe levels of various analytes (e.g. glucose, insulin, pro-insulin,c-peptide, creatinine, etc. . . . ) at fasting baseline, and then atvarious time point intervals after dosing with the glucose load. MostOGTTs and CLIX scoring require a patient to remain in the doctor'soffice for 2 hours post dose, and most clinicians only test baselinesamples and the 2 hour time point, and not the labor-intensive 3-5additional times blood draws during the 2-hour period necessary for CLIXscoring, due to labor and cost constraints. Additionally, complicatedand laborious mathematical calculations need to be performed in order tooptimize detection of at-risk individuals with these techniques, andkidney function (approximated by blood creatinine levels/eGFR) needs tobe accounted for, causing an additional step. In standard OGTTs, 1-hourtime points are rarely obtained and tested for determination of earlyinsulin resistance and/or beta cell dysfunction, even though it is knownfrom the literature that impaired first-phase insulin secretion responseto glucose load at the 1 hour time point is a predictor of risk ofdevelopment of diabetes and resulting cardio-diabetic complications suchas atherosclerosis, coronary artery disease, diabetic retinopathy, etc.

There therefore exists a need in the art for a better method fordetecting the presence of likelihood of developing occult pancreaticbeta cell dysfunction and post-prandial hyperglycemia.

SUMMARY OF INVENTION

This invention relates to a method for detecting the presence of orlikelihood of developing occult pancreatic beta cell dysfunction in apatient, comprising: (a) measuring a level of alpha-hydroxybutyrate(AHB) in a single fasting baseline biological sample of the patient; (b)comparing the level of AHB in the single fasting baseline biologicalsample to a reference AHB level; and (c) determining the presence of orlikelihood of developing occult pancreatic beta cell dysfunction in saidpatient based on the comparison in step (b). An increased AHB level atfasting baseline indicates that a normoglycemic, normo-insulinemicand/or non-dyslipidemic patient has developed or has an increasedlikelihood of developing occult pancreatic beta cell dysfunction. Thelevel of AHB may be greater than 4.5 μg/mL.

The method may include measuring one or more additional biomarkers inone or more biological samples of the patient. Biomarkers may beselected from glucose, insulin, HDL, HDL-c, triglycerides, LDL, LDL-c,C-peptide, 1, 5-anhydroglucitol, or pro-insulin. Alternatively, thebiomarkers may be auto-antibodies present in type-1 diabetes, viralnucleic acids, biomarkers to autoimmune diseases, viral DNAs, or viralRNAs and antibodies to viral capsid proteins for members of theEnterovirus family. Alternatively, the biomarkers may be glucose,insulin, anti-islet cell cytoplasmic (anti-ICA) auto-antibodies,glutamic acid decarboxylase (anti-GAD) auto-antibodies, 1,5-anhydroglucitol, hemoglobin (Hb) Alc, fructosamine, mannose,D-mannose, mannose-binding lectin (MBL) amount, mannose binding lectin(MBL) activity, 1,5-anhydroglucitol (1,5 AG), glycation gap(glycosylation gap), serum amylase, c-peptide, intact pro-insulin,leptin, adiponectin, leptin/adiponectin ratio, ferritin, free fattyacids, lipoprotein-associated phospholipase A2 (Lp-PLA2), fibrinogen,myeloperoxidase, cystatin C, homocysteine, F2-isoprostanes,a-hydroxybutyrate (AHB), linoleoyl glycerophosphocholine (L-GPC), oleicacid (OA), analytes associated with IR score, analytes associated withHOMA (Homeostasis Model Assessment) IR score, analytes associated withCLIX score, gamma-glutamic transferase (GGT), uric acid, vitamin B12,homocysteine, 25-hydroxyvitamin D, TSH, estimated glomerular filtrationrate (eGFR), or serum creatinine. Alternatively, the biomarkers may bebiomarkers associated with body mass index (BMI), free fatty acids, lowdensity lipoprotein particle number (LDL-P), LDL-cholesterol (LDL-C),triglyceride; high density lipoprotein particle number (HDL-P), highdensity lipoprotein-cholesterol (HDL-C), high sensitivity C-reactiveprotein (hs-CRP), remnant-like lipoproteins (RLPs), RLP-(cholesterolmeasures), apolipoprotein A-1, HDL2, ApoB:ApoA-1 ratio, Lp(a) mass,Lp(a) cholesterol, large VLDL-P, small LDL-P, large HDL-P, VLDL-size,LDL size, HDL size, LP-IR score, apolipoprotein A-1 (ApoA-1),apolipoprotein B (ApoB), apolipoprotein C (ApoC), apolipoprotein E(ApoE), ApoE sub-species, or variations, fragments, PTMs and isoformsthereof. Alternatively, biomarkers may be campesterol, sitosterol((3-sitosterol), cholestanol, desmosterol, lathosterol, or squalene.Alternatively, the biomarkers may be biomarkers for coagulation ordyslipidemia.

A determination of increased likelihood of an impaired first phaseinsulin secretion response can be based on the determination in 1 (c).

The presence of or increased likelihood of developing occult pancreaticbeta cell dysfunction also indicates that said patient is at risk of adiabetic condition, such as cardiodiabetes, gestational diabetes, latentautoimmune diabetes of adults (LADA), mixed phenotype diabeticconditions, or atypical forms of type 1 diabetes, such as insulinautoimmune syndrome (IAS).

The presence of or increased likelihood of developing pancreatic betacell dysfunction can also be used to predict an increased likelihood ofa requirement for exogenous insulin supplementation. The method can alsobe used to show that the patient is at risk for a cardiodiabetic diseaseassociated with post-prandial hyperglycemia. Types of cardiodiabeticdisease include retinopathy, neuropathy, nephropathy, atherosclerosis,stroke, myocardial infarction, gestational diabetes, pre-term labor, andthe birth of high birth-weight infants.

The patient may or may not show signs associated with any apparent betacell dysfunction, as detected by conventional diagnostic techniques.

Determination step (c) may be performed without having the patientprovide multiple biological samples separated by a period of time.

A health risk value may be assigned for the patient based on thedetermination in step (c), The health risk value may be low risk,moderate risk and high risk of occult pancreatic beta cell dysfunction.

In one embodiment, an AHB level of less than 4.5 μg/mL indicates a lowrisk of occult pancreatic beta cell dysfunction; an AHB level of about4.5 μg/mL to about 5.7 μg/mL indicates an intermediate to a high risk ofoccult pancreatic beta cell dysfunction; and an AHB level of more than5.7 μg/mL indicates a high risk of occult pancreatic beta celldysfunction.

The method may include measuring the anti-ICA or anti-GADauto-antibodies biomarkers in the biological sample, wherein a positivereaction to one of the biomarkers indicates an increased risk of occultpancreatic beta cell dysfunction.

A therapy guidance may be effectuated based on the determination in step(c). Suitable therapy guidance includes one or more of the following:performing a confirmatory OGTT and/or additional diagnostic testing,prescribing a drug therapy, increasing monitoring frequency of patientcondition, and recommending appropriate risk-reduction therapy such asmaking or maintaining diet and lifestyle choices based on thedetermination in step (c). The therapy guidance may involvesadministration of antioxidants, administration of anti-coagulants,administration of anti-dyslipidemic drugs, avoidance of drugs or agentsknown to damage pancreatic cells; discontinued administration of currentdrug therapy, administration of agents specific for post-prandialhyperglycemia (e.g. cycloset), administration of drugs that enhance,and/or augment, and/or spare pancreatic beta cell function,administration of an anti-viral agent, an immunosuppressant or insulinor an insulin analog or combinations thereof. The therapy guidance mayalso include one or more of the following: increased frequency ofphysician's follow-up, referral for oral glucose tolerance test (OGTT)and/or CLIX test, repetition of tests for monitoring diseaseprogression, patient referral for comprehensive testing for type Idiabetes; testing for auto-antibodies to pancreatic cell antigens, otherbiomarkers for autoimmune diseases, viral DNA/RNA and/or antibodies toviral capsid proteins for Enterovirus family members or combinationsthereof. A lifestyle choices involve changes in diet and nutrition,changes in exercise, smoking elimination or a combination thereof.

The biological sample may be a blood component, saliva or urine.

Another embodiment of the invention relates to a method for detectingthe presence of or likelihood of a patient of developing occultpancreatic beta cell dysfunction, comprising: (a) measuring a level ofalpha-hydroxybutyrate (AHB) in a biological sample of the patient; (b)comparing the level of AHB in the baseline biological sample to areference AHB level; and (c) determining the presence of or likelihoodof the patient to develop occult pancreatic beta cell dysfunction basedon the comparison in step (b). The determination in step (c) isperformed without having the patient provide multiple biological samplesseparated by a period of time. An elevated AHB baseline level indicatesthat a normoglycemic, normo-insulinemic and/or nondyslipidemic patienthas developed or has an increased likelihood of developing occultpancreatic beta cell dysfunction.

Another embodiment of the invention relates to a method for monitoringthe progression or remission or a patient's response to treatment of adiabetic condition due to occult pancreatic beta cell dysfunction in apatient, comprising: (a) measuring a first level ofalpha-hydroxybutyrate (AHB) in a biological sample of the patient; (b)measuring a second level of alpha-hydroxybutyrate (AHB) in thebiological sample of the patient after a period of time; (c) comparingthe first level and the second level of AHB in the biological samplebased on the measurements in steps (a) and (b) to determine whether thelevel of AHB has changed; and (d) monitoring the patient's progressionor remission or the patient's response to treatment of the diabeticcondition based on the comparison in step (c). An increased AHB level oran unchanged AHB level indicates that the diabetic condition is still inprogression and/or a normoglycemic, normo-insulinemic and/ornon-dyslipidemic patient is not responding to the treatment. A decreasedAHB level indicates that the diabetic condition is in remission and/or anormoglycemic, normo-insulinemic and/or non-dyslipidemic patient isresponding to the treatment. The measurement in step (b) may be taken atleast one day after the measurement in step (a).

When relating to monitoring a patient's response to a treatment, themethod may further comprise the step of adding a treatment, after themeasurement in step (a), to treat the diabetic condition; the method mayalso further comprises the step of changing and/or discontinuing atreatment, after the measurement in step (a), to treat the diabeticcondition.

Another embodiment of this invention relates to a method for detectingthe presence of or likelihood of developing clinically significantpost-prandial hyperglycemia in a patient, comprising: (a) measuring alevel of alpha-hydroxybutyrate (AHB) in a single fasting baselinebiological sample of the patient; (b) comparing the level of AHB in thesingle fasting baseline biological sample to a reference AHB level; and(c) determining the presence of or likelihood of developing clinicallysignificant post-prandial hyperglycemia based on the comparison in step(b). An increased AHB level at fasting baseline and an elevated glucoselevel of at least about 155 mg/dL at 30 minutes and/or 1 hour indicatesthat a normoglycemic, normo-insulinemic and/or non-dyslipidemic patienthas developed or has an increased likelihood of developing clinicallysignificant post-prandial hyperglycemia. The level of AHB may be greaterthan 4.5 μg/mL.

The method may include measuring one or more additional biomarkers inone or more biological samples of the patient. Biomarkers may beselected from glucose, insulin, HDL, HDL-c, triglycerides, LDL, LDL-c,C-peptide, 1, 5-anhydroglucitol, or pro-insulin. Alternatively, thebiomarkers may be auto-antibodies present in type-1 diabetes, viralnucleic acids, biomarkers to autoimmune diseases, viral DNAs, or viralRNAs and antibodies to viral capsid proteins for members of theEnterovirus family. Alternatively, the biomarkers may be glucose,insulin, anti-islet cell cytoplasmic (anti-ICA) auto-antibodies,glutamic acid decarboxylase (anti-GAD) auto-antibodies, 1,5-anhydroglucitol, hemoglobin (Hb) Alc, fructosamine, mannose,D-mannose, mannose-binding lectin (MBL) amount, mannose binding lectin(MBL) activity, 1,5-anhydroglucitol (1,5 AG), glycation gap(glycosylation gap), serum amylase, c-peptide, intact pro-insulin,leptin, adiponectin, leptin/adiponectin ratio, ferritin, free fattyacids, lipoprotein-associated phospholipase A2 (Lp-PLA2), fibrinogen,myeloperoxidase, cystatin C, homocysteine, F2-isoprostanes,a-hydroxybutyrate (AHB), linoleoyl glycerophosphocholine (L-GPC), oleicacid (OA), analytes associated with IR score, analytes associated withHOMA (Homeostasis Model Assessment) IR score, analytes associated withCLIX score, gamma-glutamic transferase (GGT), uric acid, vitamin B12,homocysteine, 25-hydroxyvitamin D, TSH, estimated glomerular filtrationrate (eGFR), or serum creatinine. Alternatively, the biomarkers may bebiomarkers associated with body mass index (BMI), free fatty acids, lowdensity lipoprotein particle number (LDL-P), LDL-cholesterol (LDL-C),triglyceride; high density lipoprotein particle number (HDL-P), highdensity lipoprotein-cholesterol (HDL-C), high sensitivity C-reactiveprotein (hs-CRP), remnant-like lipoproteins (RLPs), RLP-(cholesterolmeasures), apolipoprotein A-1, HDL2, ApoB:ApoA-1 ratio, Lp(a) mass,Lp(a) cholesterol, large VLDL-P, small LDL-P, large HDL-P, VLDL-size,LDL size, HDL size, LP-IR score, apolipoprotein A-1 (ApoA-1),apolipoprotein B (ApoB), apolipoprotein C (ApoC), apolipoprotein E(ApoE), ApoE sub-species, or variations, fragments, PTMs and isoformsthereof. Alternatively, biomarkers may be campesterol, sitosterol((3-sitosterol), cholestanol, desmosterol, lathosterol, or squalene.Alternatively, the biomarkers may be biomarkers for coagulation ordyslipidemia.

The method may further comprise administering an oral glucose tolerancetest (OGTT). If the patient exhibits a glucose level of at least about155 mg/dL and/or a decreased first phase insulin response within onehour of taking OGTT and/or after food consumption, this is an additionalindication of clinically significant post-prandial hyperglycemia, orthat the patient has developed or has an increased likelihood ofdeveloping clinically significant post-prandial hyperglycemia.

The presence of or increased likelihood of developing clinicallysignificant post-prandial hyperglycemia also indicates that said patientis at risk of a diabetic condition, such as cardiodiabetes, gestationaldiabetes, latent autoimmune diabetes of adults (LADA), mixed phenotypediabetic conditions, or atypical forms of type 1 diabetes, such asinsulin autoimmune syndrome (IAS).

The presence of or increased likelihood of developing clinicallysignificant post-prandial hyperglycemia can also be used to predict anincreased likelihood of a requirement for exogenous insulinsupplementation. The method can also be used to show that the patient isat risk for a cardiodiabetic disease associated with post-prandialhyperglycemia. Types of cardiodiabetic disease include retinopathy,neuropathy, nephropathy, atherosclerosis, stroke, myocardial infarction,gestational diabetes, pre-term labor, and the birth of high birth-weightinfants.

The method may further comprise measuring the biological sample with thebiomarker 1,5-anhydroglucitol. An elevated level of AHB and a normallevel of 1, 5-anhydroglucitol at baseline can be used as a guide todetermine whether the post-prandial hyperglycemia does not exceed theglucose renal threshold, for instance a glucose renal threshold of atleast about 180 mg/dL.

The patient may show no clinically significant post-prandialhyperglycemia, as detected by conventional diagnostic techniques.

Determination step (c) may be performed without having the patientprovide multiple biological samples separated by a period of time.

A health risk value may be assigned for the patient based on thedetermination in step (c). The health risk value may be low risk,moderate risk and high risk of occult pancreatic beta cell dysfunction.

In one embodiment, an AHB level of less than 4.5 μg/mL indicates a lowrisk of clinically significant post-prandial hyperglycemia; an AHB levelof about 4.5 μg/mL to about 6.0 μg/mL indicates an intermediate to ahigh risk of clinically significant post-prandial hyperglycemia; and anAHB level of more than 6.0 μg/mL indicates a high risk of clinicallysignificant post-prandial hyperglycemia.

The method may include measuring the anti-ICA or anti-GADauto-antibodies biomarkers in the biological sample, wherein a positivereaction to one of the biomarkers indicates an increased risk ofclinically significant post-prandial hyperglycemia.

A therapy guidance may be effectuated based on the determination in step(c). Suitable therapy guidance includes one or more of the following:performing a confirmatory OGTT and/or additional diagnostic testing,prescribing a drug therapy, increasing monitoring frequency of patientcondition, and recommending appropriate risk-reduction therapy such asmaking or maintaining diet and lifestyle choices based on thedetermination in step (c). The therapy guidance may involvesadministration of antioxidants, administration of anti-coagulants,administration of anti-dyslipidemic drugs, avoidance of drugs or agentsknown to damage pancreatic cells; discontinued administration of currentdrug therapy, administration of agents specific for post-prandialhyperglycemia (e.g. cycloset), administration of drugs that enhance,and/or augment, and/or spare pancreatic beta cell function,administration of an anti-viral agent, an immunosuppressant or insulinor an insulin analog or combinations thereof. The therapy guidance mayalso include one or more of the following: increased frequency ofphysician's follow-up, referral for oral glucose tolerance test (OGTT)and/or CLIX test, repetition of tests for monitoring diseaseprogression, patient referral for comprehensive testing for type Idiabetes; testing for auto-antibodies to pancreatic cell antigens, otherbiomarkers for autoimmune diseases, viral DNA/RNA and/or antibodies toviral capsid proteins for Enterovirus family members or combinationsthereof. A lifestyle choices involve changes in diet and nutrition,changes in exercise, smoking elimination or a combination thereof.

The biological sample may be a blood component, saliva, or urine.

Additional aspects, advantages and features of the invention are setforth in this specification, and in part will become apparent to thoseskilled in the art on examination of the following, or may learned bypractice of the invention. The inventions disclosed in this applicationare not limited to any particular set of or combination of aspects,advantages and features. It is contemplated that various combinations ofthe stated aspects, advantages and features make up the inventionsdisclosed in this application.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 shows the traditional and modern models for onset of type 1diabetic mellitus (T1DM), adapted from Atkinson and Eisenbarth, Type 1diabetes: new perspective on disease pathogenesis and treatment, TheLancet, 358(9277):221-229 (2009).

FIG. 2 illustrates a concept showing methods that accurately predictT1DM development early in the course of the disease may be clinicallyuseful in the prevention of full-blown diabetes, adapted from Atkinsonand Eisenbarth, Type 1 diabetes: new perspective on disease pathogenesisand treatment, The Lancet, 358(9277):221-229 (2009).

FIG. 3 shows the pathways that lead normal beta cells to becomedysfunctional in T1DM versus Type 2 diabetic mellitus (T2DM).

FIG. 4 shows CLIX-IR and CLIX-B graphs for patients assigned within eachof the glycemic status (NGT, IFG, IGT and CGI).

FIG. 5 shows graphs of biomarker levels for hemoglobin Alc, glucose,fructosamine and glycation gap for patients assigned within each of theglycemic status (NGT, IFG, IGT and CGI).

FIG. 6 shows graphs of biomarker levels for baseline insulin,pro-insulin, c-peptide and pro-insulin:c-peptide ratio for patientsassigned within each of the glycemic status (NGT, IFG, IGT and CGI).

FIG. 7 shows graphs of biomarker levels for leptin, adiponectin,ferritin, free-fatty acid, HDL-2 and hs-CRP for patients assigned withineach of the glycemic status (NGT, IFG, IGT and CGI).

FIG. 8 shows graphs of biomarker levels for alpha-hydroxybutyrate (AHB),linoleoyl-GC, oleic acid, IRI, HOMA-IR and LP-IR score for patientsassigned within each of the glycemic status (NGT, IFG, IGT and CGI).

FIG. 9 shows graphs of biomarkers levels for glucose, insulin, freefatty acids and c-peptide for NGT patients assigned to the followingcategories: insulin sensitive (IS), insulin resistant (IR) by highbaseline trig/HDLc ratio only, IR by high baseline AHB only or IR byboth trig/HDLc, and AHB high at baseline.

FIG. 10 is a graph depicting 1-hour glucose values measured againsttraditional GTT glycemic categories. The graph shows that a 1-hourglucose value of above 155 mg/dL was strongly associated with diabetesincidence in the Botnia and SAHS studies (during 8 years of f/u).Adapted from Abdul-Ghani et al., 2009.

FIG. 11 is a graph showing a linear relationship between a one (1)-hourglucose “bump” (mg/dL) and AHB (μg/mL) over the range 1.7 to 12.2 μg/mLin 87 normoglycemic and normo-insulinemic subjects tested.

FIG. 12 shows an ROC curve comparing the relationship between AHBmeasurement and one (1)-hour glucose held regardless of age, gender orbaseline glucose levels.

FIG. 13 shows oral glucose tolerance test (OGTT) response area under thecurve (AUC) using cubic regression with 95% mean confidence bands by AHBlevels (i.e., normal, intermediate, high).

FIG. 14 shows oral glucose tolerance test (OGTT) response area under thecurve (AUC) using cubic regression with 95% mean confidence bands by AHBlevels (i.e., normal, high).

FIG. 15 shows a distribution of beta cell CLIX score with two identifiedoutlier observations.

FIGS. 16A-C show lipid profiles of Patient X at six time points. FIG.16A shows that no lipid test was conducted on Feb. 28, 2012 and Apr. 3,2012. FIG. 16B shows the results of the lipid tests conducted on May 2,2012 and Jul. 10, 2012. FIG. 16C shows the results of the lipid testsconducted on Jan. 8, 2013 and Feb. 27, 2013.

FIGS. 17A-C show the test results for biomarkers of Glycemic Control,Beta Cell Function and Insulin Resistance of Patient X at six timepoints. FIG. 17A shows that biomarker test results from Feb. 28, 2012and Apr. 3, 2012. FIG. 17B shows biomarker test results from May 2, 2012and Jul. 10, 2012. FIG. 17C shows biomarker test results from Jan. 8,2013 and Feb. 27, 2013.

FIG. 18 shows an oral glucose tolerance test (OGTT) insulin responsearea under the curve (AUC) over time using cubic regression with 95%mean confidence bands for normal, overweight, and obese BMI categoriesby AHB tertiles.

FIG. 19 shows graphs of fitted oral glucose tolerance test (OGTT)insulin response 1^(st) phase linear slope estimate with 95% meanconfidence intervals for normal, overweight, and obese BMI groups by AHBtertiles.

FIG. 20 shows an oral glucose tolerance test (OGTT) glucose responsearea under the curve (AUC) over time using cubic regression with 95%mean confidence bands for normal, overweight, and obese BMI categoriesby AHB tertiles.

FIG. 21 shows graphs of fitted oral glucose tolerance test (OGTT)glucose response 1st phase linear slope estimate with 95% meanconfidence intervals for normal, overweight, and obese BMI groups by AHBtertiles.

FIG. 22 shows ROC curves for classifying subjects having a 1-hourglucose ≥155 mg/dL during oral glucose tolerance test (OGTT).

DETAILED DESCRIPTION

This invention provides a diagnostic tool that enables the detection andidentification of a subset of apparently normal (normoglycemic andnon-dyslipidemic) patients, from a single fasting baseline sample, whohave occult pancreatic beta cell dysfunction resulting in impairedfirst-phase insulin response. The clinical utility of the inventionarises from identification of asymptomatic patients at increased risk ofdeveloping full-blown diabetes from pancreatic insufficiency early inthe progression of the disease. This test identifies forms of diabeteswith features of both Type 1 and Type 2 and slow progression to insulininsufficiency such as (LADA), “skinny diabetes,” which is morefrequently observed in Asian populations, and atypical forms of Type 1diabetes such as Insulin Autoimmune Syndrome (IAS) in apparently normal,healthy patients. Detecting patients who would be mis-diagnosed as“normal” (no apparent beta cell dysfunction) by conventional diagnostictesting procedures will result in earlier identification of at-riskpatients so that they can be targeted for optimal therapeuticintervention to delay or prevent disease progression, and improveclinical outcomes.

Existing Test Cut-Offs and Definitions of Disease

The control of blood glucose levels is critical. Insulin is the hormonethat brings blood glucose into cells. Without sufficient insulin tobring glucose into the cells, blood glucose becomes elevated, and thecells “starve” for glucose and the body must use alternative pathways toproduce energy for vital organs, like generating ketone bodies and freefatty acids (FFA's) to fuel the brain and heart, respectively. Thepancreatic beta cells normally secrete insulin in response to a meal ora “glucose load” during an oral glucose tolerance test (OGTT), thusbringing down the level of blood glucose by bringing it into the cellsof the body. This process of glucose homeostasis can be dysregulated ina number of ways, resulting in poor control of blood glucose levels.When glucose balance is dysregulated such that blood glucose varies tohigher than normal for short or long periods of time, this means thatthe patient has developed or is developing diabetes.

Type 1 Diabetes (T1DM). There are multiple types of diabetes; it is nota single disease. Decades ago, the predominant type of diabetes wasknown as “early onset” and it was an acute illness usually occurring inchildhood or adolescence in which the patient would suddenly go fromhealthy to very sick, with high blood sugar due to rapid andcatastrophic failure of the pancreas to produce enough insulin. Thepatient would require injections of insulin in order to maintain normallevels of blood sugar and survive. Today we call this Type 1 DiabetesMellitus (T1DM) and recognize that the cause is usually viral infectionand/or autoimmunity, and that this form occurs in adults as well aschildren. Full-blown T1DM requires that patients be treated withexogenous insulin, because patients do not make enough insulin bythemselves to survive. However, there are milder forms of T1DM thatprogress more slowly to insulin-dependence, or in which a patient mayneed insulin for a short period of time, and then go off of the insulinand maintain their normal blood glucose regulation.

Type 2 Diabetes (T2DM) is completely different physiologically to T1DM.T2DM is characterized by abnormally high blood glucose and abnormallyhigh insulin levels. Also, T2DM does not have an acute onset of symptomslike T1DM. In contrast, it develops gradually over time, usually years,and therefore used to be called “adult onset” diabetes. T2DM is relatedto diet and lifestyle factors such as eating a high-sugar,high-carbohydrate diet, lack of exercise, and development of obesity, inparticular abdominal obesity. Because of the sedentary lifestyle andpoor diet in the Western world, there is an epidemic of T2DM in the USand Europe that parallels the rise in the number of obese and morbidlyobese adults. Because more children are also becoming obese, we now seemore cases of T2DM developing in childhood. The consequences fordevelopment of T2DM is a radical increase in the risk of cardiovasculardisease, termed cardiodiabetes, such as increased risk of heart attacks,strokes, high blood pressure, atherosclerosis, coronary artery disease,etc. . . . .

Insulin Resistance. The development of T2DM is preceded by years ofabnormal metabolism during which lifestyle and diet intervention,including weight loss, can completely prevent and reverse thedevelopment of the disease in most people. The earliest stage of T2DM iscalled “insulin resistance” and most patients exhibit signs of the“metabolic syndrome.” The initial clinical presentation associated withinsulin resistance is hyperinsulinemia, impaired glucose tolerance,dyslipidemia [hypertriglyceridemia and decreased high-densitylipoprotein (HDL) cholesterol] and hypertension. We also know thatchronic inflammation can help drive the development of insulinresistance. Insulin resistance is a change in physiologic regulationsuch that a fixed dose of insulin causes less of an effect on glucosemetabolism than occurs in normal individuals (blood glucose does notdrop as much or as fast as it should in response to increases ininsulin). The normal compensatory response to insulin resistance is aneven higher increase in insulin secretion that results inhyperinsulinemia. If the hyperinsulinemia is sufficient to overcome theinsulin resistance, glucose regulation remains normal; if not, type 2diabetes ensues.

“Metabolic syndrome” is associated with insulin resistance; this is acluster of metabolic abnormalities involving body fat distribution,lipid metabolism, thrombosis, blood pressure regulation, and endothelialcell function. This cluster of abnormalities is referred to as theinsulin resistance syndrome or the metabolic syndrome. Eventually, bloodglucose remains elevated even in the fasting state as the insulinresistant patient progresses towards T2DM. The pancreatic beta cellsmust work very hard to pump out this much insulin, and over time, thepancreatic islets (and the beta cells they contain) are damaged due towhat can be thought of as exhaustion. The beta cells begin to secretemore immature insulin (pro-insulin) in an attempt to keep up with thedemand, and therefore in the blood of people who are insulin resistantand well on their way to developing T2DM we see biomarkers of pancreaticbeta cell dysfunction such as higher levels of insulin, pro-insulin andc-peptide. An excellent review of Insulin Resistance and all the varioustests and indices used to diagnose insulin resistance and gauge itsseverity is “Surrogate markers of insulin resistance: A review” byBhawna Singh and Alpana Saxena, 2010.

“Pre-diabetes”. This term is essentially synonymous with insulinresistance and metabolic syndrome of Type 2 Diabetes, but has specificlab values associated with it. Doctors screen patients for diabetes ifthey have known risk factors, a family history of diabetes, high bloodpressure, BMI greater than 25, or if they have abnormal cholesterollevels (defined as HDL-C below 35 mg/dL (0.9 mmol/L) or triglyceridelevel above 250 mg/dL (2.83 mmol/L). Tests used to diagnose pre-diabetesinclude the Glycated hemoglobin (HbA1C) test (6.0 to 6.5 percent is thepre-diabetes range), a fasting blood glucose level from 100 to 125 mg/dL(5.6 to 6.9 mmol/L), or a blood glucose value of 140 to 199 mg/dL (7.8to 11.0 mmol/L) at the 2-hour time point of an OGTT. It is thiselevation of 2-hour blood glucose value that defines a patient as having“impaired glucose tolerance” (IGT. If the patient has pre-diabetes,doctors will usually test fasting blood glucose, HbA1C, totalcholesterol, HDL cholesterol, low-density lipoprotein (LDL) cholesteroland triglycerides at least once a year. Note that the above lab valuesdo not describe the patient population in which HDL is claiming utilityof elevated baseline AHB for pancreatic beta cell dysfunction.

If full-blown T2DM develops and is left undiagnosed and untreated,patients must be treated with insulin-sensitizing drugs which may helpmake their cells more responsive to insulin, and the pancreas does nothave to work as hard. Blood glucose balance can be maintained withinsulin sensitizing drugs, or maintained and/or reversed by the additionof diet and lifestyle modifications and weight loss. Unlike full-blownT1DM, T2DM may be reversible in many patients. However, if T2DMprogresses far enough, the pancreatic beta cells become unable tosecrete enough insulin on their own due to exhaustion and the patientmay progress to the last stage of T2DM wherein they cannot make enoughinsulin, and therefore will become insulin-dependent and must injectexogenous insulin to survive because their pancreatic beta cells nolonger function. This is the worst stage of T2DM and can be fatalbecause while a patient can be administered exogenous insulin, theirbody may still be resistant to its effects. These patients are atdramatically increased risk for cardio-diabetic morbidity and mortality.

Disorders of Glucose Metabolism

Disorders of glucose metabolism on the sliding scale of T2DM are definedper the following laboratory test values:

Insulin resistance (IR): a state in which higher concentrations ofinsulin are required to exert normal effects; blood glucose levels maybe normal but fasting insulin levels may be high because of compensatoryinsulin secretion by the pancreas. Optimal fasting insulin level isdefined by HDL as 3-9 μU/mL, intermediate is defined as >9 and <12, andhigh is defined as >12.

“Pre-diabetes”=Impaired glucose tolerance (IGT): glucose 140-199 mg/dL 2hours after a 75 g oral glucose load

Impaired fasting glucose: glucose 100-125 mg/dL after an 8-hour fast

Diabetes mellitus (DM): any of the following four criteria may be used(results must be confirmed by retesting on a subsequent occasion):fasting glucose >126 mg/dL; glycosylated hemoglobin (HbA1c) level >6.5%;2-hour glucose level >200 mg/dL during glucose tolerance testing; orrandom glucose values >200 mg/dL in the presence of symptoms ofhyperglycemia.

It will be appreciated by those skilled in the art of diabetesdiagnostics and treatment that the patient population in which thisinvention has clinical utility do not fit the above clinical definitionsfor insulin resistance, pre-diabetes, metabolic syndrome, impairedfasting glucose, T2DM, or T1DM (insulin-dependent). This test does notdetect insulin resistance or place a patient on a scale between normalglucose tolerance (NGT) and diabetes, because the patient population inwhich the test predicts abnormal first-phase insulin response are bydefinition NGT with normal glucose and insulin levels at baseline andthe 2 hour time point, and do not meet the definition of insulinresistance based on their lipid values on the LP-IR scale. Thus, whilefor the purpose of illustrating the utility of the invention we splitthe patients into groups by glucose tolerance and degree of insulinresistance for the purpose of analyzing data in the different groups,this is for illustrative purposes to show the utility of the test in theNGT, non-insulin resistant “normal” group. The test does not haveclinical utility as an early predictor of risk once the patient has metthe criteria for Impaired Glucose Tolerance (IGT) or Diabetes.

Relationship of First and Second-Phase Insulin Response to Beta CellFunction in Health and Diabetes

When patients are challenged with a glucose load in an OGTT, and whenthey eat meals, blood glucose rises, and the pancreatic beta cellsdetect the post-prandial rise in blood glucose. The beta cells normallyreact by releasing a rapid burst of insulin termed the “first phase”response from 2-15 minutes after a glucose load or mixed meal. The firstphase response is followed by a second phase response, which is a slowerand more sustained release of insulin sufficient to return the bloodglucose to normal fasting levels, usually by 120 minutes (2 hours).Insulin should also return to normal levels by the 2 hour time point ina healthy individual with no pancreatic beta cell dysfunction and normalglucose tolerance.

In non-diabetic individuals, half of the total daily insulin is secretedduring basal periods; this suppresses lipolysis, proteolysis, andglycogenolysis. The other half of insulin secretion occurspostprandially. In response to a meal, the first phase insulin secretionresponse should be a rapid and sizable release of preformed insulin fromstorage granules within the beta cell in non-diabetic individuals. Thefirst phase of insulin secretion promotes peripheral utilization of theprandial glucose load, and also suppresses hepatic glucose production,thus limiting postprandial glucose elevation.

Comparison of inter-individual first-phase insulin response to anintravenous glucose bolus serves as a standardized way to measure betacell function among different subjects. A blunting of or loss of firstphase response signals beta-cell declines early in the development oftype 1 or later in the development of type 2 diabetes, even whileresponses to amino acid and other stimuli may be preserved.

In Type 1 and Type 2 diabetics, first phase and second phase insulinresponses are altered in different ways during disease onset andprogression. In T2DM (as illustrated in the FIG. 1, published in TheLancet, 2009)), note that years before diagnosis of T2DM the overallinsulin secretion is greater than normal (mostly due to increased secondphase response). During this period, the cells of the patient becomemore and more resistant to the effects of insulin, causing blood glucoseto rise and despite the hyperinsulinemic state. In the classical view ofonset of T2DM, the beta cells do begin to fail later in the disease andis accompanied by insulin resistance and (usually) components of themetabolic syndrome.

T1DM has a very different presentation to T2DM. In T1DM, the diseaseprogression does not have an early hyperinsulinemic phase of increasedbeta cell function prior to the decline in function, and insulinresistance and metabolic syndrome generally do not contribute to thepathology. In T1DM, the beta cell function begins to deteriorate,usually slowly over time prior to overt symptoms of hypo-insulinemia,the resulting hyper-glycemia, and disease diagnosis. The figure belowcompares first and second phase insulin response in a normal patient vs.T1DM and T2DM patients late in the course of the disease. Note that theT2DM patients have a blunted first-phase response but enhanced secondphase, whereas the full-blown T1DM patient has no first or second phaseinsulin response and would therefore be dependent on exogenous insulinfor survival.

The complete ablation of beta cell function and insulin response in T1DMis, however, preceded by measurable incremental declines, especially inthe case of adult-onset T1DM, which tends to be more gradual and lessacute than childhood onset T1DM. The figure below illustrates thegeneral time-course of development of T1DM and correlates the loss ofbeta cell mass (loss of cells, loss of function) to various events andtriggers in the time period leading up to prior to detectable bluntedinsulin secretion and diagnosis of T1DM. Currently an asymptomaticpatient with normal baseline glucose and normal baseline insulin levelswould be considered normal and would not be screened for T1DM; in theevent that an OGTT test was performed on such a patient and the betacells were not sufficiently compromised to give abnormal 2-hour timepoint values, the early onset of blunted first phase response would bemissed. However, testing at earlier time points in an OGTT such as priorto 1 hour would reveal blunted first phase response which is theearliest indicator of deterioration of beta cell on the continuum ofT1DM development. However, in a patient with no discernible risk factorsfor development of diabetes, and/or no abnormal baseline values infasting blood glucose or insulin, a physician would not order and OGTTand thus the subclinical deterioration in beta cell function would notbe detected, resulting in a missed opportunity to identify an at-riskpatient and intervene clinically to prevent disease progression.

Until recently it was thought that the destruction of the beta cells waswholly attributable to an auto-immune attack, and that diagnosis ofdisease onset was measurable by detection of anti-pancreatic islandauto-antibodies (IAA) such as anti-GAD and others, and that onset ofdisease and destruction of beta cell function was triggered by theauto-immune reaction. Thus it was thought in the past that there was noimpaired first-phase response until after development ofauto-antibodies.

Now it is thought that the deterioration in beta cell function andimpaired first-phase response begins prior to appearance ofauto-immunity and that the development of auto-immunity is an adaptive,protective response to ongoing beta cell damage, rather than aprecipitating event in and of itself. It is now recognized that thereare metabolic abnormalities and environmental insults that, incombination with genetic risk factors predisposing a patient tosusceptibility to development of T1DM, combine to initiate developmentof the disease.

FIG. 1 shows the traditional model as well as the modern model for onsetof T1DM and illustrates that there is a clear window of beta celldecline which, if detected early, could provide an opportunity fortherapeutic intervention to delay or prevent further loss of beta cellfunction.

FIG. 2 (also published in The Lancet, 2009) illustrates the concept thattests which are able to accurately predict T1DM development early in thecourse of the disease, such as tests for early beta cell dysfunction,would be clinically useful in preventing full-blown diabetes. The earlydetection of subclinical beta cell dysfunction, including impaired firstphase insulin secretory response resulting in post-prandialhyperglycemia in the onset of any form of diabetes, is the area ofclinical utility for the test described herein.

FIG. 3 illustrates how beta cells become dysfunctional in T1DM vs. T2DM.In T1DM, oxidative stress and inflammation damage the beta cells; someindividuals seem to be more susceptible to these stressors whereasothers are more resistant and therefore less likely to develop T1DM. Thedamage and recovery or progression is a multi-factorial process that ispartially due to genetic risk factors, lifestyle, diet/nutrition,inflammatory events such as infections or autoimmune conditions,metabolic alterations, etc. Ultimately the beta cells cannot adequatelyrecover and repair and begin to secrete less insulin and also die byapoptosis, resulting in fewer functional cells and hypo-insulinemia. InT2DM by contrast there is an intermediate step before beta celldysfunction and failure wherein the beta cells may proliferate andhypertrophy as the result of hyperglycemia and insulin resistance; thisis the early phase in which the patient is hyperinsulinemic tocompensate for the hyperglycemia. The demand for insulin production aswell as the metabolic changes occurring during progression of insulinresistance to T2DM generates oxidative stress and inflammatoryresponses, and these then drive the progression of beta cell failurejust as in T1DM, but later in the disease state.

Alpha Hydroxybutyrate (AHB)

Current theories about AHB elevations in the context of diabetes arethat this metabolite is related to glucose disposal rate resulting frominsulin resistance (metabolic syndrome), and that higher levels of AHBparticularly with other metabolites such as L-GPC and Oleic Acid areuseful for placing patients on a spectrum of insulin resistance (glucosetolerance) in the development of Type 2 diabetes. However, our resultsclearly show that AHB may not be related to insulin resistance andglucose disposal rate but rather to impaired first phase insulinsecretion response that results in clinically significant post-prandialhyperglycemia in apparently NGT individuals.

AHB is also a ketone though it is not glucogenic, and therefore notdirectly related to metabolism of glucose or alternative substrates. The2 main ketone bodies are 3-hydroxybutyrate (3HB) and acetoacetate(AcAc). Therefore AHB is not produced like other ketone bodies in thecontext of altered glucose metabolism.

It is believed that AHB is produced in the liver byproduct during theformation of α-ketobutyrate (a product of either threonine catabolism ormethionine metabolism via cystathione) under conditions of excessglutathione demand resulting from high oxidative stress, or conditionsthat promote high dihydronicotinamide adenine dinucleotidel nicotinamideadenine dinucleotide (NADH/NAD+) levels, such as increased fatty acidoxidation. Glutathione (GSH) is one of the most important molecules forfighting oxidative stress in the human body. Oxidative stress may becaused by inflammation, infection, and environmental factors, and theimbalance between the generation of free radicals and a biologicalsystem's ability to readily neutralize the free radicals or to repairthe resulting damage results cellular damage and disease. Oxidativestress causes disturbances in the normal redox state of cells resultingin production of toxic peroxides and free radicals that damage proteins,lipids, and DNA by oxidation. It is known that oxidative stress cancause apoptosis and necrosis in cells, including beta cells, which arevery sensitive to oxidative damage.

Oxidative stress is involved in all aspects of damage to the body, frompancreatic beta cell damage to atherosclerosis, inflammation, andneuropathy. Autoimmunity and the chronic inflammation it causes alsoresult in significant oxidative stress. Under conditions of metabolicstress, the liver tries to synthesize as much glutathione as possiblefrom precursors L-glutamate and L-Cysteine. L-cysteine becomesrate-limiting for production of GSH under metabolic stress conditions,so more cysteine is made by diverting homocysteine away from methioninesynthesis and into a trans-sulfuration pathway to form cystathione. Whencystathione is cleaved to cysteine to make glutathione, AHB is releasedas a by-product and can be detected in blood and urine.

Therefore, the higher the oxidative and metabolic stress (such as frominflammation), the more AHB is released. Therefore it is believed thatthe appearance of elevated levels of AHB does not signal insulinresistance or the existence of Type 2 diabetes as taught in the currentliterature, but rather signals the oxidative stress leading to beta celldamage and dysfunction, as opposed to only “insulin resistance” fromhigh levels of insulin and high blood glucose. It is clear that in thestudies described above, elevated AHB in the context of baselinenormoglycemia and non-dyslipidemia is diagnostic for increasedlikelihood of impaired beta cell function resulting in impairedfirst-phase insulin response. Again this is in contrast to the teachingsof current literature which regards elevated AHB as a biomarker ofimpaired glucose disposal rates with utility for classifying patients onthe continuum of insulin resistance towards T2DM.

It should be noted that in one study, when AHB was added to culturemedium of an immortalized cell-line derived from beta cells, insulinsecretion was suppressed. Conversely, when L-GPC was added to the sameculture system, insulin secretion was stimulated. In our study, elevatedplasma AHB even in the context of normal plasma L-GPC levels werepredictive of impaired first phase response and significantpost-prandial hyperglycemia. This suggests a dominant effect of AHB tosuppress insulin secretion response even in the presence of potentiatorssuch as L-GPC that work in vitro, which was not investigated orpredicted by the in vitro study using cell lines. Furthermore, in the invivo physiological milieu of the human organism, it is known that manysubstances from hormones to metabolites to toxins and drugs) may affectbeta cell function and insulin secretion. For example, metabolites suchas glutamate and GABA may be toxic to beta cells in vitro and in vivo(and these have been related to diabetes development and progression),and beta cells may be damaged by infections (e.g. enteroviral) andauto-immune processes as well. There are thus many factors interactingin a complex system in a human organism that contribute to beta cellhealth and number and secretory ability. Thus, the results shown inthese examples could not have been predicted based on the currentliterature.

Preferred Embodiments

This invention comprises measurement of alpha-hydroxy butyrate (AHB) inblood or biological fluid of a fasted patient, wherein elevated levelsof AHB compared to a healthy population or previous test values of agiven patient are indicative of occult beta cell damage and predictiveof impaired first-phase insulin response. The test may comprisemeasurement of AHB as a single analyte, and optionally othermeasurements of other biomarkers of glycemic control and/ordyslipidemia. In the one embodiment the test comprises measurement ofalphahydroxybutyrate (AHB) alone. In a second embodiment, a panel of 3core analytes may be used: alpha-hydroxybutyrate (AHB), and the ratio oftriglycerides (trigs) to HDL-cholesterol (HDL-c). This inventionrequires only 1 baseline fasting blood sample. The sample is contactedand the amounts of the analytes are measured. A triglyceride to HDL-cratio is calculated. An elevated amount of AHB (greater than about 4.5μg/mL) measured in biological fluid from a fasting patient, particularlyin a patient who is normoglycemic and/or non-dyslipidemic (defined asnormal trig/HDLc ratio (less than 3)), indicates the presence of betacell dysfunction and/or impaired first-phase insulin response, and thusenables said patient's risk level for progression to diabetes and theco-morbidities associated with development of diabetes to be determined.As an example, in an apparently normal individual, a baseline elevationof AHB greater than about 4.5 μg/mL would therefore cause theindividual's risk to be increased from optimal to intermediate, oroptimal to high.

The elevation of AHB in the context of normoglycemia and normaltrig/HDL-c serves as a proxy for detection of the same individuals whohave abnormally high elevations of 1-hour blood glucose (greater than155 mg/dl) and impaired first-phase insulin response (which isindicative of beta cell dysfunction due to suppression or pancreaticislet damage). Because this test is able to identify a subset of at-riskpatients currently missed by standard diagnostic techniques, thesepatients can be treated earlier such that the onset of forms of diabeteslikely to require eventual treatment with exogenous insulin can bedelayed or prevented by lifestyle and diet modifications, as well aspharmacologic intervention.

Treatment options for patients identified at risk by this diagnosticmethod may comprise causing one or more of the following: increasedfrequency of follow-up, referral for OGTT including time points betweenbaseline and 2 hours, and/or CLIX, repetition of tests for monitoringdisease progression, lifestyle and diet changes, and treatment withagents to improve beta cell function such as DPP-4 inhibitors and/orGLP-1 agonists, agents to treat post-prandial glucose excursions, and/oradministration of insulin. Treatment may further comprise notadministering typical first-line drugs that would normally be used totreat insulin resistance with no beneficial effect on pancreatic betacell function, such as metformin, or adding agents which protect andenhance beta cell function to a regimen including metformin. Because thevarious embodiments of this test are proxies for decreased first-phaseinsulin response in response to glucose load of an OGTT, treatment mayalso comprise causing patient referral for comprehensive testing fordevelopment of Type-1 diabetes, such as tests for auto-antibodies topancreatic islet beta cell antigens or other biomarkers of autoimmunedisease (e.g. rheumatoid factor as a non-limiting example), and/or viralDNA/RNA and/or antibodies to viral capsid proteins for members of theenterovirus family that are known to cause pancreatic beta cell deathand/or impairment of function. In the case of patients who arepresumptively positive for any degree of enteroviral infection, and/orType-1 Diabetes, and/or LADA, the treatment may comprise administeringone or more of the following: an anti-viral agent, an immunosuppressant,insulin or an insulin analog, agents known to those skilled in the artto preserve beta cell function, agents that prevent post-prandialglucose excursions (e.g. Cycloset), and lifestyle and diet changescommonly prescribed for avoidance of development of Type 2 diabetes suchas low-carbohydrate diets. Treatment may further comprise causing theavoidance of drugs or agents known to damage pancreatic islet cells.

Other treatments to reduce or ameliorate cardiovascular risk(cardiodiabetes) based on the results of this test further comprisecontacting the patient sample, measuring the analytes included on HDL'spanel tests for dyslipidemia, inflammatory biomarkers, and/or otherbiomarkers of cardiovascular disease, and determining the associatedrisk levels (optimal, intermediate, or high) for one or more of theseanalytes, and recommending appropriate risk-reduction therapy based onsaid determining. Therapy may comprise causing treatment with agents orlifestyle/diet changes for the improvement of these conditions. Thisimproved risk stratification for future cardiodiabetes morbidity andmortality allows for therapeutic strategies such as those listed above,but not limited to those listed above, to be prescribed in order toameliorate risk of development of cardiodiabetes and improvement ofdisease condition in existing cardiodiabetes.

The test panel may be used once, or repeatedly, for initial diagnosis ofoccult pancreatic beta cell dysfunction and/or for monitoring diseaseprogression and/or for monitoring response to treatment. The biologicalsample is contacted, tested by means known to those skilled in the art,and the results are measured and reported to a qualified healthcareprovider and/or patient. The report may take the form of a writtenreport, a verbal discussion, a faxed report, or an electronic reportaccessed by a computing device or hand-held smart-phone device. Adiagnostic and therapeutic nomogram based on the initial analytemeasurements and the corresponding risk levels as well as otherincidental laboratory test values and patient history, and comments maybe added to the report based on this diagnostic nomogram that aid indata interpretation, diagnosis, and choice of therapy. Qualifiedhealthcare provider is defined as a physician (MD, DO), nurse,registered dietician, pharmacist, or other appropriately trainedindividual qualified to counsel patients on health-related issues.

Beyond use of the test described herein to detect occult beta celldysfunction and identify patients likely to display impaired first phaseinsulin response and progress to full-blown diabetes, additionalbiomarkers may be added to further improve diagnosticsensitivity/specificity and detection of and/or determination of risk ofdeveloping T1DM and the future cardiodiabetes complications. Short termpost-prandial glucose elevations such as those demonstrated in patientswith impaired first-phase insulin response are a known risk factor fordevelopment of many cardiodiabetic complications. As a non-limitingexamples, biomarkers from the group comprising 1,5-AG, auto-antibodiesrelated to type-1 diabetes, viral nucleic acids, antigens and/orantibodies to viral capsid proteins, biomarkers of dyslipidemia,metabolites related to the altered metabolism resulting from oxidativestress, and inflammatory biomarkers may be measured in addition to thecore analytes previously described to further improve determination ofpatient risk level. In some embodiments only measurements of the corediagnostic analytes are used to classify patients' risks of progressionas being optimal, intermediate, or high. In other embodiments the coreanalytes plus one or more additional analytes may be used to classifypatients as optimal, intermediate, or high. In some cases a score may becalculated based on the measurement of core analytes plus additionalanalytes, and the mathematically derived score may be utilized todetermine patient risk level, and said determining shall be used toguide treatment decisions.

In the preferred embodiment, the biological sample contacted is a bloodcomponent (serum or plasma). In other embodiments, other biologicalfluids comprising urine, saliva, or a combination of any biologicalfluids, may be contacted, and measurements of the analytes determined.It will be understood that all analytes need not be measured in the samefluid, i.e. 1,5 AG may be measured in urine or plasma and viral geneticmaterial or proteins may be measured in cellular material, regardless ofthe biological sample type in which the other analytes are measured.

There have been no previous studies or reports in the literature of atest based on AHB alone or in combination with other analytes useful forpredicting a priori which patients who are apparently normoglycemic(NGT) with apparently normal pancreatic beta cell function, are morelikely to have clinically significant post-prandial glucose excursionsgreater than 155 mg/dl at 1 hour time point, and who are therefore atincreased risk of cardiodiabetic complications. This novel test enablesre-classification of “low- or optimal-risk” patients who would beconsidered normal by conventional diagnostics to be re-assigned to ahigher risk category based on baseline elevations of AHB alone or incombination with other analytes. Taken together, the low insulin andelevated blood glucose at the “halfway point” of an OGTT are indicativeof impaired beta cell function that is undetectable in the fasting stateusing conventional screening test methods. This test is unique in itsability to identify via elevated AHB, at a fasting baseline time point,the normoglycemic, normo-insulinemic, non-dyslipidemic patients whowould be missed by existing diagnostic techniques who have impaired betacell function sufficient to cause a decreased first-phase insulinresponse, and who are therefore at higher risk of beta cell exhaustionand progression to an insulin-dependent form of diabetes mellitus (IDDM)in the future. Because some forms of diabetes, such as LADA, may followa relapsing/remitting pattern common to other auto-immune diseases,measuring baseline AHB will provide a means to monitor deterioration orimprovement of pancreatic function and response to therapy even inintermediate forms of diabetes.

The measurement of AHB at baseline, without or without additionalbaseline analytes, allows for the identification of patients who haveimpaired beta cell function who would not be detected using theconventional diagnostic analytes (glucose, HbA1c, and insulin) atbaseline. Because measurement of AHB at baseline reliably predicts whichpatients have beta cell dysfunction/impaired first phase response, OGTTsmay be avoided in some cases. This would result in fewer blood samplesbeing drawn from the patient due to elimination of multiple time points,a shorter time to obtain samples (no 2-hour waiting period for patient),fewer analytes needing to be measured, lower testing costs, shorterturn-around times for laboratory test results, no additionalcalculations needed such as CLIX scores to interpret data, and no needto account for impairment of kidney function (creatinine, eGFR).Measurement of elevated AHB can reclassify patients who are apparentlylow-risk to intermediate or high-risk of developing futurecardiodiabetic disease due to beta cell dysfunction.

Examples

Study No. 1:

A study was done wherein 100 patients were sampled at baseline (fasting)and again at 30 minutes, 1 hour, 90 minutes, and 2 hours post glucoseload in an OGTT. Analytes listed in FIGS. 1-4 were measured. For eachfigure, glycemic status of the each patient was categorized into NGT,IFG, IGT, and CGI according to standard guidelines issued by theAmerican Diabetes Association (see DIABETES CARE, vol. 20, sup. 7, Jul.1997). The figures then show whether the 1 hour glucose was above orbelow 155 mg/dL, which is the cutoff value established in the literatureas a post-prandial hyperglycemic excursion value associated withincreased risk of diabetes and resulting cardio-diabetic complications;this 1 hour cutoff value is further associated with decreased firstphase insulin secretion response due to occult beta cell dysfunction inNGT individuals (see Abdul-Ghani and DeFronzo, DIABETES CARE, vol. 32,sup. 2, Nov. 2009). CLIX scores were calculated based on the measuredanalytes, as a measure of insulin sensitivity. Patients were assigned toa group based on their CLIX scores: Normal Glucose Tolerance (NGT),Impaired Fasting Glucose (IFG), Impaired Glucose Tolerance (IGT), andComplete Glucose Intolerance (CGI). As noted in the figures below,approximately 20% of normoglycemics at baseline will be detected asat-risk (insulin resistant) by CLIX scoring. See FIG. 4.

FIGS. 5-8 show the values of various markers measured in each patientwithin the four glycemic status category and with 1-hour glucose cutoffdistinctions. A marker that effectively predicts occult beta celldysfunction will have a large value for the NGT red bar (high 1-hourglucose, the indication of beta cell dysfunction) and a low value forthe NGT blue bar (regular 1-hour glucose).

Individual biomarkers measured at baseline were then studied todetermine how well they would be able to predict which patients wouldhave blood glucose elevated above 155 mg/dl at one hour, a value whichhas been associated in the literature and in longitudinal clinicalstudies (Botnia, SAHS) to be associated with development of diabetes andcardiodiabetic complications in the future. 1 hour glucose levels alsostrongly stratified risk within each traditional GTT glycemic category(Abdul-Ghani, et. al, 2008, 2009).

FIG. 5 shows the lack of predictive power of common diagnostic tests fordiabetes, namely HbA1c, Glucose, Fructosamine, and Glycation Gap. FIG. 6shows the lack of predictive value of baseline insulin, pro-insulin,c-peptide, and proinsulin:c-peptide ratio. FIG. 7 shows the lack ofpredictive power for leptin, adiponectin, ferritin, free fatty acid,HDL-2, and hs-CRP.

Other biomarkers used to quantify insulin resistance, namely alphahydroxybutyrate, Linoleoyl-GPC, Oleic Acid, IRI Score, HOMA-IR score,and LP-IR score were further studied. AHB in isolation was the onlysingle biomarker that had significant predictive power for classifyingwhich NGT patients would have blood glucose above 155 at 1 hour.

FIG. 8 shows a lack of predictive value for common biomarkersLinoleoyl-GPC, Oleic Acid, HOMA-IR and LP-IR Score. AHB(a-hydroxybutyrate) shows strong predictive power in this figure. IRIscore, which incorporates measurement of AHB, L-GPC, Oleic Acid, and amathematical weighting by either BMI (in this study) or baseline insulin(formula currently in clinical diagnostic use) also shows statisticallyrelevant results, however, the score's weighting by BMI limits itsclinical utility to detection of patients with significant insulinresistance in the context of metabolic syndrome and/or hyper-insulinemiaand dyslipidemia.

In FIG. 9, the NGT patients were assigned to categories of IS (insulinsensitive), IR (insulin resistant) by high baseline trig/HDLc ratioonly, IR by high baseline AHB only, or IR by both trig/HDL-c and AHBhigh at baseline. The levels of Glucose, Insulin, Free Fatty Acids, andC-peptide at each of the time points in the study were then compared foreach of these groups. In the upper left panel, there is a cleardifference between 1 hour glucose actually measured between the IS group(AHB not elevated at baseline, blue) and the IR-AHB group (only AHBelevated at baseline, green). The group with only elevated baseline AHBhas significantly higher 1 hour blood glucose than the IS controls,demonstrating the utility of this biomarker as a proxy for 1 hourglucose measurements. In the upper right panel, it can be clearly seenthat by 1 hour the insulin secretion in the group with elevated baselineAHB was markedly lower than controls, demonstrating that 1) the abilityof the pancreatic beta cell to secrete insulin in response to a glucosechallenge is impaired, and 2) this less than optimal insulin secretionmay be the cause of the elevated blood glucose values at 1 hour in thisgroup.

This line of evidence is further reinforced by data on blunted C-peptidesecretion (FIG. 9 bottom right panel) in the group with elevatedbaseline AHB. C-pep is released when pro-insulin is cleaved to insulinand declining levels of C-pep and increased pro-insulin to C-pep ratiois associated with a decline in beta cell function. The abnormally lowlevels of C-pep at 1 hour post-glucose challenge correspond to theabnormally low insulin levels and serve as confirmation that there isindeed less insulin secreted in the NGT group with elevated baselineAHB. Because elevated AHB only, at baseline, in normoglycemicnon-dyslipidemic subjects, is able to predict which patients will haveimpaired insulin secretion and therefore 1 hour post-challenge glucoseexcursions, it has clinical utility in identifying patients that wouldnormally be mis-classified as normal and at low risk of developingdiabetes and reclassifying them properly into a category of increasedrisk. The data trends shown in FIG. 9 support the conclusion thatelevated baseline AHB is strongly associated with beta cell dysfunctionand impaired first phase insulin response.

It is also worth noting in FIG. 9 that all of the patients were testedfor anti-GAD antibody, which is the most common auto-antibody topancreatic beta cells in Type 1 diabetics. All of the patients werenegative for anti-GAD, which is significant because impaired insulinsecretion on glucose challenge could be indicative of the presence ofType 1 diabetes. However, just because the patients were negative forthe most common auto-antibody detected in Type 1 diabetics does not meanthat they are not early-stage Type 1's or LADAs (Latent AutoimmuneDiabetes in Adults) or suffering from Insulin Auto-immune Syndrome (IAS)wherein the body produced auto-antibodies to insulin that can alsoresult in slow progression to insulin-dependent diabetes. IAS patientstypically have hypoglycemic episodes and normal or low-normal insulinlevels at baseline, meaning that the standard tests for glycemic controlsuch as HbA1c, fructosamine, and glycation gap would be normal and notraise any suspicion of presence of IAS until it progresses to abnormallylow levels of insulin and pancreatic beta cell dysfunction sufficient tocause symptoms.

So it is possible that some of the patients with elevated baseline AHBwho exhibit abnormally low insulin levels and abnormally high glucoselevels at 1 hour in an OGTT could be positive for one of the otherautoantibodies detectable in Type 1 diabetics that HDL did not test for,or they may have occult damage to their pancreatic beta cells from apast or current viral infection, such as enterovirus infections, thatis/was not severe enough to be detected at baseline and is onlyobservable when the patient is challenged with a glucose load in anOGTT.

Additional validation of the 1 hour glucose levels as a marker forfuture diabetes risk is presented in FIG. 10. The data show that a1-hour glucose level of 155 mg/dL or higher is strongly associated withdiabetes incidence in the Botnia and SAHS (San Antonio Heart Study). Itis noted that the 1-hour glucose reading strongly stratified risk withineach traditional GTT glycemic category (see Abdul-Ghani and DeFronzoDIABETES CARE, vol. 32, sup. 2, Nov. 2009).

Study No. 2:

OGTTs with multiple time points were performed on 222 subjects. Patientswith any signs of impaired glucose tolerance, or T1DM were excluded perthe table below (Table 1), leaving a total of 87 subjects who werenormoglycemic and normo-insulinemic. Patient population was mixed sex,mixed race, various ages, and on various medications. This was an“all-comers” study to test the strength of the predictive power of AHBin an apparently normal population.

TABLE 1 Define non-insulin resistant subjects Condition (in order) N Alloral glucose tolerance tests with AHB 222 AntiGad > 5 6 Insulin 0 hr >12 78 Glucose 0 hr ≥ 100 20 Glucose 2 hr ≥ 140 17 HbA1c missing 6 HbA1c≥ 5.7 6 Glucose 1 hr missing 1 BMI missing 1 Total sample size 87

There were 87 subjects that were not insulin resistant by currentclinical definitions (Table 1). The mean (SD) glucose elevation abovebaseline at 1-hour was 33(34) mg/dL. The relationship between the 1-hourglucose ‘bump’ and alpha-hydroxybutyrate (AHB) was linear over the range1.7 to 12.2 ug/mL (FIG. 11).

FIG. 11 shows that AHB predicts a change in glucose at 1-hour usinglinear regression with 95% mean confidence band. Each 1 ug/mL increasein fasting AHB was correlated with 6.4 mg/dL higher 1-hour glucoselevels (p<0.0001) following an oral glucose tolerance test (Table 2).Furthermore, the variability in AHB explained about 16% of thevariability in elevated 1-hour glucose levels. Per these results, if asubject is just below a fasting glucose of 100 mg/dL, then a mean 55mg/dL elevated 1-hour glucose would equate to an AHB of 8.2 ug/mL. Thisrelationship between AHB measurement and 1-hr glucose held regardless ofage, gender, or baseline glucose levels (Tables 3 & 4, FIG. 12).

The strength of the relationship between AHB and elevated 1-hour glucoselevels remained, but was slightly attenuated in subgroups of thehealthiest patients. One of these subgroups was defined by reducing thebaseline insulin level to ≤9 for inclusion. Then a 1 unit increase inAHB was correlated with 5.3 mg/dL higher 1-hour glucose levels(p=0.0044, N=69). The healthiest patients were also defined by excludingdyslipidemias measured by triglyceride to HDL cholesterol ratio(Tg/HDLC) or LP-IR score. When subjects with Tg/HDLC ≥3 were excluded,then a 1 unit increase in AHB was correlated with 5.1 mg/dL higher1-hour glucose levels (p=0.0031, N=61). Similar results were obtainedwhen subjects with LP-IR>50 were excluded, then a 1 unit increase in AHBwas correlated with 4.3 mg/dL higher 1-hour glucose levels (p=0.027,N=52).

Fasting AHB levels were also used to predict the probability of having a1-hour glucose level ≥155 mg/dL. For each 1 unit increase in AHB apatient was 1.6 times as likely to have levels above this threshold(Table 5, p=0.0005). Also the model fit was calibrated across riskdeciles of having an elevated 1-hour glucose (Hosmer-Lemeshow p=0.99).AHB was effective in discriminating patients; the area under the ROCcurve was 0.79 for AHB alone, which was greater than chance (p<0.0001,FIG. 12).

FIG. 12 shows discrimination of patients with 1-hour glucose ≥155 mg/dL.In that figure the base model included age, gender, BMI, and baselineglucose. Adding AHB to a model with age, baseline glucose and genderincreased the AUC from 0.62 to 0.79 (p=0.027). The sum of sensitivityand specificity were at a maximum with an AHB cut point ≥6.8; 53% and93%, respectively (Table 12). This resulted in a positive likelihoodratio (PLR) of 7.8, which meant a patient with an AHB≥6.8 was almost 8times as likely to have a 1-hour glucose ≥155 mg/dL. A good clinicaltest has a PLR>3 and an excellent test has a PLR>6.

These data are evidence that fasting alpha-hydroxybutyrate is aneffective risk marker for elevated glucose levels at 1-hour following anoral glucose tolerance test. The results are consistent when 1-hourglucose levels are modeled continuously or dichotomously using a knownthreshold (≥155 mg/dL) of increased risk for development ofcardiodiabetic diseases.

TABLE 2 AHB predicts change in 1-hour glucose using linear regressionAnalysis of Variance Sum of Mean F Source DF Squares Square Value Pr > FModel 1 17481 17481 18.08 <.0001 Error 86 83172 967.11064 CorrectedTotal 87 100652 Root MSE 31.09840 Dependent Mean 33.36364 Coeff Var93.21047 R-Square 0.1737 Adj R-Sq 0.1641 Parameter Estimates ParameterStandard t Variable DF Estimate Error Value Pr > |t| Intercept 1 2.525087.97521 0.32 0.7523 AHB 1 6.37190 1.49874 4.25 <.0001

TABLE 3 AHB predicts change in 1-hour glucose using linear regressionmodel adjusted for age, gender, baseline glucose and their interactionswith AHB. AHB, age, and glucose were mean centered. Analysis of VarianceSum of Mean Source DF Squares Square F Value Pr > F Model  7 206752953.54743 2.95 0.0083 Error 80 79978 999.71915 Corrected Total 87100652 Root MSE 31.61834 R-Square 0.2054 Dependent Mean 33.36364 AdjR-Sq 0.1359 Coeff Var 94.76885 Parameter Estimates Parameter StandardVariance Variable DF Estimate Error t Value Pr > |t| Inflation Intercept1 33.49118 4.69663 7.13 <.0001 0 ahb_cl 1 6.26981 2.41269 2.60 0.01112.50697 age_cl 1 0.01641 0.24530 0.07 0.9468 1.06289 glue0_cl 1 0.083210.48601 0.17 0.8645 1.07353 Male 1 0.29552 6.96140 0.04 0.9662 1.05763ahb_age 1 0.15014 0.12292 1.22 0.2255 1.40144 ahb_gluc0 1 0.130730.25092 0.52 0.6038 1.30816 ahb_male 1 −0.04190 3.51283 −0.01 0.99052.82172

TABLE 4 AHB predicts change in 1-hour glucose using linear regressionmodel adjusted for age, gender, and baseline glucose. Analysis ofVariance Sum of Mean Source DF Squares Square F Value Pr > F Model 417569 4392.14936 4.39 0.0029 Error 83 83084 1001.00923 Corrected Total87 100652 Root MSE 31.63873 R-Square 0.1745 Dependent Mean 33.36364 AdjR-Sq 0.1348 Coeff Var 94.82998 Parameter Estimates Parameter StandardVariance Variable DF Estimate Error t Value Pr > |t| Inflation Intercept1 −3.47725 40.81224 −0.09 0.9323 0 AHB 1 6.34436 1.53574 4.13 <.00011.01443 Age 1 0.01727 0.24161 0.07 0.9432 1.02983 GLUC0 1 0.053900.48127 0.11 0.9111 1.05134 Male 1 1.60269 6.89453 0.23 0.8168 1.03607

TABLE 5 AHB predicts 1-hour glucose ≥ 155 mg/dL using logisticregression model adjusted for age, gender, and baseline glucose TestingGlobal Null Hypothesis: BETA = 0 Test Chi-Square DF Pr > ChiSqLikelihood Ratio 17.9144 4 0.0013 Analysis of Maximum LikelihoodEstimates Standard Wald Parameter DF Estimate Error Chi-Square Pr >ChiSq Intercept 1 −10.9372 4.7377 5.3294 0.0210 AHB 1 0.5007 0.143312.2000 0.0005 Age 1 0.0139 0.0239 0.3374 0.5613 Male 1 0.0484 0.65940.0054 0.9415 GLUC0 1 0.0689 0.0518 1.7707 0.1833 Odds Ratio EstimatesPoint 95% Wald Effect Estimate Confidence Limits AHB 1.650 1.246 2.185Age 1.014 0.968 1.063 Male 1.050 0.288 3.822 GLUC0 1.071 0.968 1.186Hosmer and Lemeshow Goodness-of-Fit Chi-Square DF Pr > ChiSq 1.5677 80.9915

The prior AHB results are supported in statistical models adjusted forage, gender, baseline glucose, and BMI (Tables 6 & 7, FIG. 12). Therelations between AHB and various OGTT endpoints including glucose,insulin, C-peptide, and proinsulin are summarized in Table 8. The AHBslope estimates to 30-minute and 1-hour glucose excursion (FIGS. 5 & 6).AHB has the following results:

-   -   1) Linear relation with the 1-hour and 30-minute glucose        measurement (Table 8, p<0.0009)    -   2) Associated with the probability of having a 1-hour        glucose >155 mg/dL (Table 7, p=0.0005)    -   3) Association is calibrated across the range of data (Table 7,        Hosmer-Lemeshow p=0.69)    -   4) AHB adds to the discrimination of subjects having a 1-hour        glucose ≥155 mg/dL; the area under the ROC curve increases by        16% (FIG. 12, p=0.039) compared to a model with age, gender,        BMI, and baseline glucose (FIG. 12).

Several variable selection methods were explored to determine if othervariables could assist AHB in explaining variability in the 1-hourglucose ‘bump’ and classifying patients with 1-hour glucose ≥155 mg/dL.LGPC had a significant linear relation with the 1-hour glucosemeasurement (Table 9, p=0.038); however, it did not add any informationto classifying subjects above the 155 mg/dL 1-hour threshold (Table 10,p=0.35).

Correlations were determined with AHB and FFA, CLIX-IR, CLIX-Beta Cell,CRP, and Lp-PLA2 (Table 11). Pearson correlations assume a bivariatenormal distribution, such that at least both variables are normallydistributed. These assumptions can be investigated using severalmethods; basic tools available are the skewness and kurtosis measures.As a rule-of-thumb when the absolute value of the skewness is greaterthan 3, or kurtosis is greater than 10, the normality assumption is nottenable. In these data the CLIX-Beta Cell measure had absolute skew=6.6and kurtosis=44 (Table 11), which identified two outlier observations(FIG. 15). When normality is not reasonable and the variables arecontinuous measures, then Spearman's Rank correlation should be usedinstead. In these raw data, the Pearson's correlation for CLIX-Beta Cellwith AHB was r=0.12, p=0.28. However, since the data are non-normalSpearman's correlation was a more accurate measure r=−0.30, p=0.0046.When the two outliers were removed, which may or may not be appropriatedepending if they are viable measurements, then Pearson's correlationcorrectly identified the magnitude and direction of the linear relation,r=−0.32, p=0.00289 (Table 11).

These data are evidence that fasting alpha-hydroxybutyrate is aneffective risk marker for elevated glucose levels at 30 minutes and1-hour following an oral glucose tolerance test. The results areconsistent when 1-hour glucose levels are modeled continuously ordichotomously using a known threshold (≥155 mg/dL) of increased risk forprogression to diabetes. Using the current empirically determined HDLguidelines for AHB high risk level (i.e. >5.7 ug/mL), produces apositive likelihood ratio (PLR) of 3.1. This means a patient with anAHB>5.7 is about 3 times as likely to have a 1-hour glucose >155 mg/dL.

These results were not influenced by age, gender, BMI, or baselineglucose levels. These results were also not affected by anyanti-diabetic medications, lipid altering medications, or fish oil.However, the medication status of 40 (45%) of the subjects was unknown.The strength of the relationship between AHB and elevated 1-hour glucoselevels remained in subgroups of the healthiest patients defined as thosewithout dyslipidemias measured by triglyceride to HDL cholesterol ratio(Tg/HDLC) or LP-IR score, or when lowering the level of fasting insulinfrom ≤12 to ≤9 for inclusion.

FIG. 13 shows oral glucose tolerance test responses using cubicregression with 95% confidence bands by AHB levels (i.e. normal,intermediate, high). FIG. 14 shows oral glucose tolerance test responsesusing cubic regression with 95% confidence bands by AHB levels (i.e.normal, high). FIG. 15 shows a distribution of beta cell CLIX score withextreme IDs=834498, 924352.

TABLE 6 AHB predicts change in 1-hour glucose using linear regressionmodel adjusted for age, gender, BMI, and baseline glucose. Analysis ofVariance Sum of Mean Source DF Squares Square F Value Pr > F Model 517402 3480.33690 3.44 0.0071 Error 81 81839 1010.35298 Corrected Total86 99240 Root MSE 31.78605 R-Square 0.1753 Dependent Mean 33.79310 AdjR-Sq 0.1244 Coeff Var 94.06076 Parameter Estimates Parameter StandardVariance Variable DF Estimate Error t Value Pr > |t| Inflation 95%Confidence Limits Intercept 1 −14.21410 43.89913 −0.32 0.7469 0−101.55959 73.13140 AHB 1 6.28384 1.54464 4.07 0.0001 1.01576 3.210489.35720 Age 1 0.03713 0.24473 0.15 0.8798 1.04269 −0.44982 0.52407 GLUC01 0.12484 0.49249 0.25 0.8005 1.06678 −0.85506 1.10474 Male 1 1.034067.10739 0.15 0.8847 1.08040 −13.10741 15.17553 BMI 1 0.16036 0.571330.28 0.7797 1.05721 −0.97642 1.29713

TABLE 7 AHB predicts 1-hour glucose ≥ 155 mg/dL using logisticregression model adjusted for age, gender, BMI, and baseline glucoseTesting Global Null Hypothesis: BETA = 0 Test Chi-Square DF Pr > ChiSqLikelihood Ratio 17.9447 5 0.0030 Analysis of Maximum LikelihoodEstimates Standard Wald Parameter DF Estimate Error Chi-Square Pr >ChiSq Intercept 1 −11.2959 4.9384 5.2319 0.0222 AHB 1 0.4978 0.143112.1004 0.0005 Age 1 0.0147 0.0240 0.3718 0.5420 Male 1 0.0116 0.67350.0003 0.9862 GLUC0 1 0.0722 0.0526 1.8850 0.1698 BMI 1 0.00290 0.05460.0028 0.9576 Odds Ratio Estimates Point 95% Wald Effect EstimateConfidence Limits AHB 1.645 1.243 2.178 Age 1.015 0.968 1.064 Male 1.0120.270 3.787 GLUC0 1.075 0.970 1.192 BMI 1.003 0.901 1.116 Hosmer andLemeshow Goodness-of-Fit Test Chi-Square DF Pr > ChiSq 5.6005 8 0.69

TABLE 8 Summary of AHB relations in linear regression models adjustedfor age, gender, and BMI Response N Slope 95% CI P-value (1 hr-0 hr)Glucose 87 6.3  3.2 to 9.4 <0.0001 (30 min-0 hr) Glucose 75 4.7  2.0 to7.5 0.0009 (1 hr-0 hr) Insulin 87 0.2 −4.5 to 4.9 0.94 (30 min-0 hr)Insulin 75 −2.0 −6.2 to 2.1 0.34 (1 hr-0 hr) C-peptide 87 0.2 −0.1 to0.4 0.21 (30 min-0 hr) C-peptide 75 −0.1 −0.3 to 0.1 0.38 Proinsulin 86−0.3 −1.3 to 0.6 0.48 Proinsulin/C-peptide 86 −0.2 −0.6 to 0.2 0.32

TABLE 9 AHB and LGPC predict change in 1-hour glucose using linearregression model adjusted for age, gender, BMI, and baseline glucose.Analysis of Variance Sum of Mean Source DF Squares Square F Value Pr > FModel 6 21730 3621.68424 3.74 0.0025 Error 80 77510 968.87713 CorrectedTotal 86 99240 Root MSE 31.12679 R-Square 0.2190 Dependent Mean 33.79310Adj R-Sq 0.1604 Coeff Var 92.10989 Parameter Estimates ParameterStandard Variance 95% Confidence Variable DF Estimate Error t Value Pr >|t| Inflation Limits Intercept 1 27.41477 47.28563 0.58 0.5637 0−66.68663 121.51618 AHB 1 5.53930 1.55308 3.57 0.0006 1.07085 2.448578.63003 Age 1 0.02658 0.23971 0.11 0.9120 1.04315 −0.45046 0.50362 Male1 4.92029 7.19874 0.68 0.4963 1.15580 −9.40566 19.24624 BMI 1 −0.175450.58160 −0.30 0.7637 1.14246 −1.33288 0.98198 GLUC0 1 0.09669 0.482460.20 0.8417 1.06759 −0.86343 1.05681 LGPC 1 −1.36742 0.64695 −2.110.0377 1.23672 −2.65489 −0.07995

TABLE 10 AHB and LGPC predict 1-hour glucose ≥ 155 mg/dL using logisticregression model adjusted for age, gender, BMI, and baseline glucoseTesting Global Null Hypothesis: BETA = 0 Test Chi-Square DF Pr > ChiSqLikelihood Ratio 18.8646 6 0.0044 Analysis of Maximum LikelihoodEstimates Standard Wald Parameter DF Estimate Error Chi-Square Pr >ChiSq Intercept 1 −8.3845 5.5756 2.2613 0.1326 AHB 1 0.4641 0.144710.2890 0.0013 LGPC 1 −0.0680 0.0728 0.8709 0.3507 Age 1 0.0124 0.02400.2680 0.6047 Male 1 0.1278 0.6948 0.0339 0.8540 GLUC0 1 0.0651 0.05231.5477 0.2135 BMI 1 −0.0230 0.0614 0.1397 0.7086 Odds Ratio EstimatesPoint 95% Wald Effect Estimate Confidence Limits AHB 1.591 1.198 2.112LGPC 0.934 0.810 1.078 Age 1.013 0.966 1.061 Male 1.136 0.291 4.436GLUC0 1.067 0.963 1.183 BMI 0.977 0.866 1.102

TABLE 11 Correlations with AHB Variable N Mean Std Dev Minimum MaximumSkewness Kurtosis AHB 88 4.840 2.225 1.700 12.200 1.325 1.745 FFA0 880.558 0.243 0.120 1.250 0.825 0.423 CLIX_IR 88 7.642 3.472 1.880 17.2000.926 0.318 CLIX_Bcell 88 2.883 49.047 −360.890 36.660 −6.610 44.426hsCRP 72 2.206 2.850 0.300 15.000 2.544 6.698 Lp_PLA2_DSX 67 140.53740.382 54.000 249.000 0.306 0.048 CLIX_Bcell 86 10.177 5.885 2.26036.660 1.577 3.846 FFA0 CLIX_IR CLIX_Bcell hsCRP Lp_PLA2_DSX PearsonCorrelation Coefficients Prob > |r| under H0: Rho = 0 AHB 0.45767−0.35768 0.11665 0.10306 0.17367 <.0001 0.0006 0.2791 0.3890 0.1599 8888 88 72 67 Spearman Correlation Coefficients Prob > |r| under H0: Rho =0 AHB 0.55913 −0.39366 −0.29947 0.19634 0.11334 <.0001 0.0001 0.00460.0983 0.3611 88 88 88 72 67 Pearson Correlation Coefficients Prob > |r|under H0: Rho = 0 AHB −0.31780 0.0029 86

TABLE 12 Diagnostic metrics for AHB thresholds AHB Threshold ≥ TrueFalse [ug/mL] Positive Positive Sensitivity Specificity 1.5 15 73 100.00.0 1.8 15 72 100.0 1.4 2.2 15 70 100.0 4.1 2.3 15 68 100.0 6.8 2.4 1565 100.0 11.0 2.6 15 64 100.0 12.3 2.8 15 63 100.0 13.7 2.9 15 62 100.015.1 3.0 15 60 100.0 17.8 3.1 15 58 100.0 20.5 3.2 15 54 100.0 26.0 3.314 52 93.3 28.8 3.4 14 50 93.3 31.5 3.5 14 46 93.3 37.0 3.7 14 44 93.339.7 3.8 13 43 86.7 41.1 3.9 12 38 80.0 47.9 4.1 12 35 80.0 52.1 4.3 1234 80.0 53.4 4.4 12 33 80.0 54.8 4.5 12 31 80.0 57.5 4.6 11 27 73.3 63.04.7 11 26 73.3 64.4 4.8 11 23 73.3 68.5 5.0 10 21 66.7 71.2 5.1 10 1966.7 74.0 5.4 9 18 60.0 75.3 5.5 9 17 60.0 76.7 5.6 9 16 60.0 78.1 5.7 915 60.0 79.5 6.0 9 14 60.0 80.8 6.1 9 13 60.0 82.2 6.2 9 11 60.0 84.96.5 8 10 53.3 86.3 6.6 8 9 53.3 87.7 6.7 8 7 53.3 90.4 6.8 8 5 53.3 93.27.1 7 5 46.7 93.2 7.2 6 4 40.0 94.5 7.5 6 3 40.0 95.9 7.7 6 2 40.0 97.37.8 5 2 33.3 97.3 9.3 5 1 33.3 98.6 9.5 3 1 20.0 98.6 10.5 2 1 13.3 98.611.0 1 1 6.7 98.6Case Study:

Patient X is a female aged 40 with normal weight, normal fastingglucose, insulin levels, free fatty acid, and lipid levels at the timeof the first serial blood draw for metabolic testing on Feb. 8, 2012.Tests were repeated at 6 time points with the last test being performedon Feb. 27, 2013. Patient has no evidence of metabolic syndrome orType-2 diabetes but does have a history of late gestational diabetes in2 pregnancies 8 and 6 years previously which required insulin therapy.Gestational diabetes resolved after delivery and insulin therapy was nolonger required. Patient tested negative for anti-GAD antibodies, theclassical test for detection of Type 1 diabetes (auto-immune), butpatient is positive for Rheumatoid Factor and has been diagnosed with anauto-immune connective tissue disorder (data not shown). However,despite her auto-immune status, tests for biomarkers of inflammationduring the course of the year-long follow were unremarkable, however itis possible that auto-immune flares may still skew metabolic testresults (tests included Myeloperoxidase, Lp-PLA2, hs-CRP, andFibrinogen, data not shown).

FIG. 16 shows lipids of Patient X at 6 time points. In FIG. 16A it isindicated that tests were not performed on Feb. 28, 2012 and Apr. 3,2012.

In FIG. 16B, results from May 2, 2012 (far right column under previousresults) and Jul. 10, 2012 (values to left of risk ranges) are shownindicating that the patient is normolipidemic.

In FIG. 16C, results from Jan. 28, 2013 (far right column under previousresults) and Feb. 27, 2013 (values to left of risk ranges) are shownindicating that the patient is normolipidemic.

FIG. 17 shows biomarkers of Glycemic Control, Beta Cell Function, andInsulin Resistance. In FIG. 17A, results from Feb. 28, 2012 (far rightcolumn under previous results) and Apr. 3, 2012 (results to left of riskranges) are shown. Feb. 28, 2012: Fasting blood glucose, FFA, andinsulin are all normal. Apr. 3, 2012: Patient was not fasting, so bloodglucose and insulin values as well as scores derived therefrom (HOMA IR)cannot be compared to other panels. However, AHB and FFA levels areoptimal, and measures of glycemic control such as HbA1c, Fructosamineand Glycation Gap are normal, indicating that blood glucose iswell-controlled.

In FIG. 17B, results from May 2, 2012 (far right column under previousresults) and Jul. 10, 2012 (values to left of risk ranges) are shown.May 2, 2012: patient is still normoglycemic, normo-insulinemic and hasnormal levels of FFA, and AHB. There would be no reason to suspect onthe face of these common screening test results that this patient hadcompromised pancreatic beta cell dysfunction and no evidence ofdeteriorating condition. Jul. 10, 2012: AHB and FFA levels increase forthe first time above the optimal range into the high-risk range. Patientis mildly hypoglycemic (69, close to optimal range of 70 and withinexperimental error), with optimal insulin levels, and is stillnormolipidemic. A standard screening test for fasting blood glucose andinsulin would not pick up any deterioration in beta cell function orcause a physician to suspect the onset of deterioration of the patient'scondition.

In FIG. 17C, results from Jan. 28, 2013 (far right column under previousresults) and Feb. 27, 2013 (values to left of risk ranges) are shown.Jan. 28, 2013: AHB is again elevated beyond the threshold of 4.5 intothe intermediate risk category while FFA are still in the optimal range.Glucose and insulin are still within the optimal range. Interestingly, anew test for post-prandial glucose index (1,5-anhydro-glucitol levels,also known as GlycoMark) is only very slightly elevated over the optimalrange (6.1 vs. 6.0). Feb. 26, 2013: AHB levels have increased to a newhigh of 7.7, and FFA are also again elevated to the high risk range. Onthis date the patient was hypoglycemic but the estimated daily averageglucose was within the optimal range, as was insulin.

Discussion of Data in FIGS. 16 and 17.

These figures collectively show that elevated AHB can be detected atbaseline in a patient whose fasting glucose, insulin, and blood lipidsare all within normal limits. In FIG. 16C, there are a number ofobservations worth pointing out. For instance, despite other normalvalues of glycemic control and the patient being hypoglycemic on Feb.26, 2013, and though HbA1c is in the optimal range at 5.1, this is thehighest value for HbA1c recorded over a 1 year period where all othervalues fell between 4.7 and 4.9; taken together with the elevated Jan.28, 2013 intermediate elevation in post-prandial glucose index, theindicate that post-prandial glucose excursions are occurring, possiblycausing elevations in glycosylated hemoglobin over the previous months.These results suggest that if an OGTT had been done in the precedingmonths, abnormal elevations of blood glucose (and blunted secretion ofinsulin and C-peptide) would have been detected at 1 hour and/or 30minutes. Also worth noting: while fasting insulin levels are normal, onthe last blood draw date, pro-insulin and c-peptide were abnormally highfor the first time, and the pro-insulin: c-peptide ratio was alsoelevated to the high risk range; this is significant. The appearance ofpro-insulin and c-peptide are indicators of beta cell dysfunction; theseare released when the pancreas is working to produce insulin as fast aspossible in response to high blood sugar (for example in the context ofType 2), or due to deterioration of pancreatic beta cells that thenspill immature forms of insulin into the bloodstream (such as in betacell lysis/damage in auto-immune context of Type 1), or a combination ofboth conditions. In conditions like this where pancreatic beta cells arebeing destroyed or exhausted, low and low-normal levels of insulinproduction do not evidence health, but rather progressing disease. It isin this case that one may observe normal levels of fasting insulintogether with lower-than-normal levels of insulin at 1 hour in an OGTTbecause the pancreatic beta cells “cannot keep up with the demand” inresponse to elevated blood sugar. Because the first abnormal elevationof AHB and FFA occurred in July 2012 and the first evidence ofpancreatic beta cell dysfunction occurred in February 2013, there was an8-month window from the time elevated AHB signaled a decline inpancreatic beta cell function and the time such dysfunction could bedefinitively measured by detection of immature forms of insulin in thebloodstream.

The invention described herein would allow for detection of abnormalbeta cell function in a patient who otherwise showed no signs ofimpending beta cell dysfunction by standard diagnostic screeningmethods, and would have allowed for therapeutic intervention 8 monthsearlier than conventional diagnostic techniques. It is also worth notingthat because this patient was thin and the weight and BMI were lowestfor the last test wherein the AHB was highest and the beta cell functionhad deteriorated the greatest, elevated fasting AHB may a biomarker forthe onset of “skinny diabetes”, which is a form of adult-onset Type 1(most commonly observed in Asian populations) requiring exogenousinsulin therapy and completely different in etiology to Type 2/metabolicsyndrome.

Study No. 3:

In study 3, 217 consecutive nondiabetic subjects underwent a 75 g oralglucose tolerance test (OGTT) and fasting blood collection to evaluaterisk of diabetes between March 2012 and May 2013 at several outpatientcenters across the US (Madison, Wis.; Jackson, Miss.; Montgomery, Ala.;Charleston, S.C.; Seattle, Wash.; and Salt Lake City, Utah). Clinicalindications for testing included obesity, history of first-degree familymembers with diabetes, and presence of one or more components of themetabolic syndrome, including impaired fasting glucose. Samples weresent by overnight courier to Health Diagnostic Laboratory, Inc.(Richmond, Va.) for measurement of glucose, insulin, metabolites, andother biomarkers. Subjects with detectable anti-GAD antibody (titer >5IU/ml) were excluded. Patient characteristics and results are shown intable 13.

Insulin resistance (IR) was defined by one or more of the followingconditions: fasting glucose ≥100 mg/dL, 2-hour glucose ≥140 mg/dL,HbA1c≥5.7%, fasting insulin ≥12 μU/mL. Transient hyperglycemia (TH) wasdefined as 30, 60, or 90-minute glucose ≥140 mg/dL during OGTT. Thefinal study group consisted of 90 IR subjects and 85 healthy subjectswith normal levels for all these criteria.

General linear mixed models were used with restricted maximum likelihood(REML) estimation to analyze the mean response profiles for insulin andglucose changes over the 3- or 5-time point 2-hour OGTT. A cubicregression model was fit to the data since the curve's characteristicswere known to include two inflection points. The unstructured repeatedmeasures covariance matrix was chosen since it minimized Akaike'sInformation Criterion (AIC). The insulin response was transformed usingthe natural transformation to improve the normality and homoscedasticityof the residual errors. To determine if AHB modified the insulin orglucose response, interactions were tested between tertiles of AHB withtime, time, and time using F-tests and Wald tests. Interactions werealso tested between BMI categories (i.e. normal <25, 25≤overweight ≤30,and obese ≥30 kg/m2) and the cubic time response.

Multivariable logistic regression was used to test the association (i.e.odds ratio) and incremental improvement in discrimination (i.e.c-statistic) of subjects with 1-hour glucose ≥155 mg/dL when AHB wasadded to age, gender, BMI, fasting glucose, Ln(fasting insulin),Ln(triglycerides), HDL-C, and LDL-C. Fasting insulin and triglycerideswere natural logarithm transformed to reduce leverage of extremeobservations. When testing the usefulness of a novel biomarker, theAmerican Heart Association recommends reporting the marker's statisticalassociation, discrimination, calibration, and reclassificationperformance. Hosmer-Lemeshow was used as a measure of model calibration.The reclassification was tested when AHB was added to the fully adjustedlogistic regression model with the integrated discrimination improvement(IDI) metric, which can be described as the average increase insensitivity given no change in specificity. The percentage of subjectswho had model probabilities changed in the correct direction (i.e.,increased for those with events and decreased for non-events) due to theaddition of AHB to the fully adjusted model was tested with thecontinuous net reclassification index (NRI). SAS® version 9.3 (Cary,N.C.) was used for all analyses, with the critical level set to 0.05 toprescribe statistical significance. Results are shown in table 14.

FIG. 18 shows results from Study 3. OGTT insulin response over timeshown with cubic regression and 95% mean confidence bands for normal,overweight, and obese BMI categories by AHB tertiles. In linear mixedmodels, the 1^(st) phase insulin linear slopes were independent of BMI(p=0.16) in models adjusted for age, gender, BMI, fasting glucose,Ln(HbA1c), Ln(triglycerides), HDL-C, and LDL-C. The lowest AHB tertilehad a 1st phase linear slope that was 1.67 and 1.33 units greater thanthe 2^(nd) and 3^(rd) tertiles, respectively (minimum p=0.0008). Theincreased slope in the lowest AHB tertiles compared to the highertertiles shows that the first phase insulin secretion response issuppressed in terms of amount of insulin released and rate of release byincreasing amounts of plasma AHB. There was no difference in the 1^(st)phase linear slopes between the 2^(nd) and 3^(rd) AHB tertiles (p=0.39)in fully adjusted models.

FIG. 19 Shows fitted OGTT insulin response 1^(st) phase linear slopeestimate with 95% mean confidence intervals for normal, overweight, andobese BMI groups by AHB tertiles. * p-value<0.05 compared to 1^(st)tertile; there were no differences between 2^(nd) and 3^(rd) tertiles(minimum p-value=0.12).

FIG. 20 shows OGTT glucose response over time shown with cubicregression and 95% mean confidence bands for normal, overweight, andobese BMI categories by AHB tertiles. In linear models, the glucose areaunder the curve (AUC) was independent of BMI (p=0.55) in models adjustedfor age, gender, BMI, fasting insulin, Ln(triglycerides), HDL-C, andLDL-C. The lowest AHB tertile had a glucose AUC that was 32 and 42 unitslower than the 2^(nd) and 3^(rd) tertiles, respectively (minimump=0.0065), further supporting the decreased first phase insulin responsedue to beta cell dysfunction as AHB levels increase. The independence ofthe effect from BMI further underscores the assertion herein thatincreased levels of AHB are not related to metabolic syndrome/insulinresistance phenomena as currently taught in the literature. There was nodifference in the glucose AUC between the 2^(nd) and 3^(rd) AHB tertiles(p=0.37) in fully adjusted models.

FIG. 21 shows OGTT glucose response area under the curve (AUC) shownwith 95% mean confidence intervals for normal, overweight and obese BMIgroups by AHB tertiles; * p-value<0.05 compared to 1^(st) tertile; therewere no differences between 2^(nd) and 3^(rd) tertiles (minimump-value=0.39). There were no significant differences betweencorresponding AHB tertiles between BMI groups.

FIG. 22 shows ROC curves for classifying subjects having a 1-hourglucose ≥155 mg/dL during OGTT. The area increased by 0.039 (95% CI:0.008 to 0.070, p=0.015) when AHB was added to age, gender, BMI, fastingglucose, Ln(fasting insulin), Ln(Triglycerides), HDL-C, and LDL-C in thelogistic regression model.

TABLE 13 Patient characteristics grouped by BMI category [kg/m²] LinearBMI < 25 25 ≤ BMI < 30 BMI ≥ 30 P- Trend Variable n = 37 n = 66 n = 114value* P-value Age [years] 53.6 (17.8) 53.5 (15.0) 49.3 (13.1) 0.0980.12 Male: n (%) 14 (38) 43 (65) 39 (34) 0.0002 n/a Fasting Glucose[mg/dL] 84 (9)  92 (14) 95 (16) 0.0003 <0.0001 1-hr Glucose [mg/dL] 130(55)  139 (50)  157 (53)  0.0083 0.0060 2-hr Glucose [mg/dL] 103 (53) 119 (62)  126 (50)  0.078 0.024 HbA1c† [%] 5.2 (0.4) 5.4 (0.5) 5.6 (0.8)0.0010 0.0005 Fasting Insulin† [uU/mL] 5.8 (3.6) 10.2 (7.1)  19.2 (16.1)<0.0001 <0.0001 Triglycerides† [mg/dL] 78 (44) 121 (117) 149 (122)<0.0001 <0.0001 HDL Cholesterol [mg/dL] 68 (20) 56 (18) 52 (14) <0.0001<0.0001 LDL Cholesterol [mg/dL] 93 (34) 112 (40)  104 (36)  0.040 0.13CLIX-IR†  9.8 (10.2) 6.5 (3.6) 4.3 (2.4) <0.0001 <0.0001alpha-hydroxybutyrate [ug/mL] 5.4 (3.3) 5.3 (2.7) 5.1 (2.2) 0.77 0.56Anti-GAD Positive: n(%)  1 (2.7)  3 (4.6)  4 (3.5) 0.88 n/a InsulinResistant: n (%) 11 (30) 32 (48) 78 (68) <0.0001 n/a 1-hr Glucose ≥ 155[mg/dL]: n (%) 11 (30) 19 (29) 58 (51) 0.0049 n/a TransientHyperglycemia: n (%) 17 (46) 34 (52) 77 (68) 0.023 n/a Data are mean(SD) unless stated otherwise; *One-way ANOVA and Chi-squared test forcontinuous and categorical data, respectively; †Used natural logarithmtransformation for improved normality and homoscedasticity of residualerrors in linear models.

TABLE 14 ROC curve comparisons for classifying subjects having a 1-hourglucose ≥ 155 mg/dL during OGTT (Study #3) AUC (c-statistic) AUC WithoutWith Difference P-value AHB AHB (95% CI) Difference Model 1: Age, Gender0.632 0.739 0.107 (0.043 to 0.172) 0.0011 Model 1 + BMI 0.702 0.7750.073 (0.021 to 0.126) 0.0066 Model 1 + fasting glucose 0.786 0.8360.050 (0.014 to 0.086) 0.0069 Model 1 + Ln(HbA1c) 0.753 0.807 0.054(0.011 to 0.098) 0.014 Model 1 + Ln(fasting insulin) 0.751 0.821 0.071(0.026 to 0.115) 0.0019 Model 1 + Ln(trigs), HDL-C, LDL-C 0.727 0.7870.060 (0.015 to 0.106) 0.0098 All covariates 0.821 0.857 0.037 (0.005 to0.069) 0.025 The area increased by 0.037 (95% CI: 0.005 to 0.069, p =0.025) when AHB was added to age, gender, BMI, fasting glucose,LN(HbA1c), Ln(fasting insulin), Ln(Triglycerides), HDL-C, and LDL-C inthe logistic regression model.

Although preferred embodiments have been depicted and described indetail herein, it will be apparent to those skilled in the relevant artthat various modifications, additions, substitutions, and the like canbe made without departing from the spirit of the invention and these aretherefore considered to be within the scope of the invention as definedin the claims which follow.

What is claimed is:
 1. A method of treating post-prandial hyperglycemiain a patient having impaired first-phase insulin response comprising: a.measuring a level of alpha-hydroxybutyrate (AHB) in a single fastingbaseline biological sample of the patient; b. comparing the level of AHBin the single fasting baseline biological sample to a reference AHBlevel; and c administering to the patient a diabetes therapy if thelevel of AHB in the single fasting baseline biological sample isdetermined to be at least 6.0 μg/mL.
 2. The method of claim 1, furthercomprising measuring one or more biomarkers in one or more biologicalsamples of the patient.
 3. The method of claim 2, wherein the one ormore biomarkers are selected from the group consisting of glucose,insulin, HDL, HDL-c, triglycerides, LDL, LDL-c, C-peptide,1,5-anhydroglucitol, and pro-insulin.
 4. The method of claim 2, whereinthe one or more biomarkers are selected from the group consisting ofauto-antibodies present in type-1 diabetes; viral nucleic acids;biomarkers to autoimmune diseases; viral DNAs, viral RNAs and antibodiesto viral capsid proteins for members of the Enterovirus family.
 5. Themethod of claim 2, wherein the one or more biomarkers are selected fromthe group consisting of glucose, insulin, anti-islet cell cytoplasmic(anti-ICA) auto-antibodies, glutamic acid decarboxylase (anti-GAD)auto-antibodies, 1,5-anhydroglucitol, hemoglobin (Hb) A1c, fructosamine,mannose, D-mannose, mannose-binding lectin (MBL) amount, mannose bindinglectin (MBL) activity, 1,5-anhydroglucitol (1,5 AG), glycation gap(glycosylation gap), serum amylase, c-peptide, intact pro-insulin,leptin, adiponectin, leptin/adiponectin ratio, ferritin, free fattyacids, lipoprotein-associated phospholipase A2 (Lp-PLA2), fibrinogen,myeloperoxidase, cystatin C, homocysteine, F2-isoprostanes, linoleoylglycerophosphocholine (L-GPC), oleic acid (OA), analytes associated withIR score, analytes associated with HOMA (Homeostasis Model Assessment)IR score, analytes associated with CLIX score, gamma-glutamictransferase (GGT), uric acid, vitamin B12, homocysteine,25-hydroxyvitamin D, TSH, estimated glomerular filtration rate (eGFR),and serum creatinine.
 6. The method of claim 5, further comprisingmeasuring the biological sample with the biomarker 1,5-anhydroglucitol,wherein an elevated level of AHB and a normal level of1,5-anhydroglucitol at baseline are used as a guide to determine whetherthe post-prandial hyperglycemia does not exceed a glucose renalthreshold.
 7. The method of claim 6, wherein the glucose renal thresholdis at least about 180 mg/dL.
 8. The method of claim 5, furthercomprising measuring the anti-ICA or anti-GAD auto-antibodies biomarkersin the biological sample, wherein a positive reaction to one of thebiomarkers indicates an increased risk of clinically significantpost-prandial hyperglycemia.
 9. The method of claim 2, wherein the oneor more biomarkers are selected from the group consisting of body massindex (BMI); free fatty acids; low density lipoprotein particle number(LDL-P); LDL-cholesterol (LDL-C); triglyceride; high density lipoproteinparticle number (HDL-P); high density lipoprotein-cholesterol (HDL-C);high sensitivity C-reactive protein (hs-CRP); remnant-like lipoproteins(RLPs); RLP-(cholesterol measures); apolipoprotein A-1; HDL2;ApoB:ApoA-1 ratio; Lp(a) mass; Lp(a) cholesterol; large VLDL-P; smallLDL-P; large HDL-P; VLDL-size; LDL size; HDL size; LP-IR score;apolipoprotein A-1 (ApoA-1); apolipoprotein B (ApoB); apolipoprotein C(ApoC); apolipoprotein E (ApoE); and ApoE sub-species, variations,fragments, PTMs and isoforms thereof.
 10. The method of claim 2, whereinthe one or more biomarkers are selected from the group consisting ofcampesterol, sitosterol (β-sitosterol), cholestanol, desmosterol,lathosterol, and squalene.
 11. The method of claim 2, wherein the one ormore biomarkers are biomarkers for coagulation or dyslipidemia.
 12. Themethod of claim 1, further comprising administering an oral glucosetolerance test (OGTT), wherein a glucose level of at least about 155mg/dL and/or a decreased first phase insulin response within one hour oftaking OGTT and/or after food consumption indicates that the patient hasdeveloped or has an increased likelihood of developing clinicallysignificant post-prandial hyperglycemia.
 13. The method of claim 1,wherein presence of or increased likelihood of developing clinicallysignificant post-prandial hyperglycemia also indicates that said patientis at risk of a diabetic condition selected from the group consisting ofcardiodiabetes, gestational diabetes, latent autoimmune diabetes ofadults (LADA), mixed phenotype diabetic conditions, and atypical form oftype 1 diabetes.
 14. The method of claim 13, wherein the atypical formof type 1 diabetes is insulin autoimmune syndrome (IAS).
 15. The methodof claim 1, wherein presence of or increased likelihood of developingclinically significant post-prandial hyperglycemia further predicts anincreased likelihood of a requirement for exogenous insulinsupplementation.
 16. The method of claim 1, wherein the patient is atrisk for a cardiodiabetic disease associated with post-prandialhyperglycemia.
 17. The method of claim 16, wherein the cardiodiabeticdisease is selected from the group consisting of retinopathy,neuropathy, nephropathy, atherosclerosis, stroke, myocardial infarction,gestational diabetes, pre-term labor, and high birth-weight infants. 18.The method of claim 1, wherein the patient shows no clinicallysignificant post-prandial hyperglycemia, as detected by conventionaldiagnostic techniques.
 19. The method of claim 1, wherein thedetermination in step (c) is performed without having the patientprovide multiple biological samples separated by a period of time. 20.The method of claim 1, further comprising assigning a health risk valuefor the patient based on the determination in step (c), wherein a healthrisk value is selected from the group consisting of moderate risk andhigh risk of clinically significant post-prandial hyperglycemia.
 21. Themethod of claim 20, wherein an AHB level of more than 6.0 μg/mLindicates a high risk of clinically significant post-prandialhyperglycemia.
 22. The method of claim 1, further comprisingeffectuating a therapy guidance based on the determination in step (c).23. The method of claim 22, wherein the therapy guidance involves drugtherapy, additional diagnostic testing, additional monitoring frequencyand recommendations of appropriate risk-reduction therapy and on makingor maintaining lifestyle choices based on the determination in step (c).24. The method of claim 23, wherein the lifestyle choices involvechanges in diet and nutrition, changes in exercise, smoking elimination,and/or a combination thereof.
 25. The method of claim 22, wherein thetherapy guidance involves administration of antioxidants, administrationof anti-coagulants, administration of anti-dyslipidemic drugs, avoidanceof drugs or agents known to damage pancreatic cells; discontinuedadministration of current drug therapy, administration of agentsspecific for post-prandial hyperglycemia (e.g. cycloset), administrationof drugs that enhance and/or spare pancreatic beta cell function,administration of an anti-viral agent, an immunosuppressant or insulinor an insulin analog or combinations thereof.
 26. The method of claim22, wherein the therapy guidance involves increased frequency ofphysician's follow-up, referral for oral glucose tolerance test (OGTT)and/or CLIX test, repetition of tests for monitoring diseaseprogression, patient referral for comprehensive testing for type 1diabetes; testing for auto-antibodies to pancreatic cell antigens, otherbiomarkers for autoimmune diseases, viral DNA/RNA and/or antibodies toviral capsid proteins for Enterovirus family members or combinationsthereof.
 27. The method of claim 1, wherein the biological sample isselected from the group consisting of a blood component, saliva andurine.
 28. A method of treating post-prandial hyperglycemia comprisingadministering to a patient a diabetes therapy, wherein the patient isdetermined to have an impaired first-phase insulin response based on alevel of AHB in the single fasting baseline biological sample of atleast 6.0 μg/mL.